Bought  of 

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404  North  8Th  Street, 

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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT 


Mrs,  Janet  White 
St,   John's  Hospital 


<{/„^  ///^/-^^ 


>J 


DISEASES  OF  THE  EYE. 


A  HANDBOOK 


DISEASES  OF  THE  EYE 


AXD   THEIR 


TREATMENT 


HENRY  R.  JSWANZY,  A.M.,  M.B.,  F.R.C.S.I. 

SURGEON  TO  THE  NATIONAL  EYE  AND  EAR  INFIRMARY,  AND  OPHTHALMIC  SURGEON   TO 

THE  ADELAIDE  HOSPITAL,   DUBLIN;    EXAMINER  IN  OPHTHALMIC  SURGERY 

IN   THE   UNIVERSITY   OF  DUBLIN,  AND   IN  THE  ROYAL 

UNIVERSITY   OF   IRELAND 


FOURTH    EDITION 

WITH    ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTON,    SON    &    CO 

1012   WALNUT    STREET 
1892 


Copyright,  1892,  by  P.  Blakiston,  Son  &  Co. 


Phess  of  Wm.  F.  Fell  &  Co 

1220-24  Sansom  St.. 

philadelphia. 


WW 
loo 


I     DEDICATE    THIS     BOOK 

TO 

THEODORE   LEBER, 

PROFESSOR  AT  THE  UXIVERSITT  OF   HEIDELBERG, 

AS  A  MARK  OF 

MY  ADMIRATION  FOR  HIS  EMINENT  SERVICES 

TO  OPHTHALMOLOGY, 

AND  OF 
MY  SINCERE  REGARD. 


PREFACE  TO  THE  FOURTH  EDITION. 


The  Third  Edition  of  this  book  was  published  in  October, 
1890,  and  I  am  gratified  that  the  work  continues  to  find  favor, 
not  only  with  students,  for  whom  it  is  mainly  intended,  but 
also  with  practitioners. 

The  book  has  now  again  been  revised  throughout,  and 
brought  up  to  date. 

In  an  Appendix,  Holmgren's  Method  for  Testing  the  Color 
Sense  has  been  described  in  greater  detail  than  before. 

Some  new  illustrations  have  been  added. 

The  great  difficulty  of  an  author  in  the  preparation  of  a 
book  like  this  consists  in  "  Saying  not  all  he  might,  but  all 
he  ought."  It  is  his  duty  to  give  a  succinct  and  practical 
account  of  his  subject  in  its  most  modern  aspect,  without 
weighting  his  pages  with  excessive  detail  and  prolonged  dis- 
cussion. This  has  been  my  aim.  For  deeper  and  wider  infor- 
mation, larger  handbooks,  and  original  monographs,  must  be 
consulted. 

23  Meriox  Square, 
October,  1892. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Some  Elementary  Optics — Numbering  of  Trial-Lenses  and  Spec- 
tacle Glasses — Normal  Refraction  and  Accommodation — The 
Metre  Angle — The  Angle  Gamma — The  Sense  of  Sight  (Light- 
Sense,  Color-Sense,  Form-Sense) — The  Field  of  Vision  ...  1 


CHAPTER  IL 

ABXORMAL    REFRACTION   AND    ACCOMMODATIOX. 

Hjpermetropia — Correction  of  H. — Amplitude  of  Accommodation 
in  H. — Angle  Gamma  in  H  — Cramp  of  Ciliary  Muscle  in  H. — 
Accommodative  Asthenopia  in  H. — Internal  Strabismus  in 
H. — The  Prescribing  of  Spectacles  in  H 25 

Myopia — Determination  of  Degree  of  M. — Amplitude  of  Accom- 
modation in  M. — Angle  Gamma  in  M. — Complications  of  Pro- 
gressive M. — Management  of  M. — The  Prescribing  of  Specta- 
cles in  M 31 

Astigmatism — Symptoms  of  As.  —  Estimation    of    Degree  of,  and 

Correction  of  As. — Lental  As. — Irregular  As 39 

Anisometropia 49 

Anomalies  of  Accommodation — Presbyopia — Paralysis  of  Accom- 
modation— Cramp  of  Accommodation 49 

CHAPTER   III. 

THE    OPHTHALMOSCOPE. 

Why  Necessary — Helmholtz's  Ophthalmoscope — Modern  Ophthal- 
moscope— Direct  Method — Indirect  Method 56 

Estimation  of  the  Refraction  by  aid  of  the  Ophthalmoscope — Direci 

Method — Retinoscopy 63 

Focal  Illumination ,    .    , 76 

ix 


X  CONTENTS. 

PAGF. 

The  Normal  Fundus  Oculi  as  seen  with  the  Ophthalmoscope — The 
Optic  Papilla — The  Retina — The  Macula  Lutea — The  General 
Fundus  Oculi — The  Retinal  Vessels 77 

CHAPTER   IV. 

DISEASES    OF   THE    CONJUKCTIVA. 

Hyperaemia — Conjunctivitis — Catarrhal,  or  Simple  Acute  Conjunc- 
tivitis—  Follicular  Conjunctivitis  —  Spring  Catarrh  —  Granular 
Conjunctivitis,  Granular  Ophthalmia,  or  Trachoma — Acute 
Granular  Ophthalmia— Chronic  Granular  Ophthalmia — Acute 
Blennorrhoea  of  the  Conjunctiva,  or  Purulent  Ophthalmia — 
Croupous  Conjunctivitis— ^Diphtheritic  Conjunctivitis  —  Con- 
junctival Complication  of  Smallpox — Amyloid  Degeneration 
— Tubercular  Disease  of  the  Conjunctiva — Lupus  —  Pem- 
phigus —  Xerophthalmos  —  Pterygium  —  Pinguecula  —  Subcon- 
junctival Ecchymosis— Polypus — Dermoid  Tumors — Syphilitic 
Disease  of  the  Conjunctiva — Papilloma,  or  Papillary  Fibroma 
— Epithelioma — Sarcoma — Simple  Cysts — Subconjunctival  Cys- 
ticercus — Lithiasis — Injuries  of  the  Conjunctiva 82 

CHAPTER  V. 

PHLYCTENULAR,    OR    STRUMOUS,    CONJUNCTIVITIS    AND    KERATITIS. 

Solitary,  or  Simple,  Phlyctenula  of  the  Conjunctiva — Multiple,  or 
Miliary,  Phlyctenula  of  the  Conjunctiva — Modes  of  Secondary 
Corneal  Affection — Primary  Phlyctenular  Keratitis— Different 
Forms  of  Same — Symptoms  of  Phlyctenular  Keratitis — Causes 
of  Phlyctenular  Ophthalmia — Treatment 123 

CHAPTER  VI. 

THE  DISEASES  OF  THE  EYELIDS. 

Eczema — Herpes  Zoster  Ophlhalmicus — Primary  Syphilitic  Sores — 
Secondary  Syphilitic  Sores — Vaccine  Vesicles— Rodent  Ulcer 
— Marginal  Blepharitis  (Ophthalmia  Tarsi)— Phtheiriasis  Cili- 
orum — Hordeolum  (Stye) — Chalazion  (Meibomian  Cyst,  Tarsal 
Tumor) — Mi  Ilium — Molluscum — Njevus — Xanthelasma — Chro- 
midrosis — Epithelioma,  Sarcoma,  and  Lupus — Clonic  Cramp 
of  the  Obicularis  Muscle — Blepharospasm — Ptosis— Operations 
for   its  Cure— Lagophthalmos — Symblepharon  —  Blepharophi- 


CONTENTS.  XI 

PAGE 

mosis  — Canthoplastic  Operation — Distichiasis  and  Trichiasis — 
Operations  for  their  Cure — Entropium — Operations  for  its  Cure 
— Spastic  Entropium — Senile  Entropium — Operations  for  its 
Cure — Ectropium — Operations  for  its  Cure— Ankyloblepharon 
— The  Restoration  of  an  Eyelid — Injuries — Ecchymosis — Epi- 
canthus — Congenital  Coloboma 132 

CHAPTER   Vir. 

THE    DISEASES    OF    THE    LACHRYMAL   APPARATUS. 

Malposition  of  the  Punctum  Lachrymale — Stenosis  and  Occlusion  of 
thePunctum  Lachrymale — Obstruction  of  the  Canaliculus — Stric- 
ture of  the  Nasal  Duct — Blennorrhoea  of  the  Lachrymal  Sac — 
Acute  Dacryocystitis  —  Dacryoadenitis  —  Hypertrophy  of  the 
Lachrymal  Gland 1T4 

CHAPTER   VIIL 

THE    DISEASES    OF    THE    CORNEA. 

Inflammations  of  the  Cornea — (a)  Ulcerative  Inflammations  of  the 
Cornea — Simple  Ulcer — Deep  Ulcer — Ulcus  Serpens — Rodent 
Ulcer — Marginal  Ring  Ulcer — Absorption  L^lcer — Neuro- Para- 
lytic Keratitis — Infantile  L'lceration  of  the  Cornea  with  Xerosis 
of  the   Conjunctiva — Herpes — Thread  like  Keratitis — Bullous 

Keratitis — Dendriform   Keratitis 184 

(6)  Non  Ulcerative  Inflammations  of  the  Cornea — Abscess — Dif- 
fuse   Interstitial    Keratitis — Keratitis    Punctata — Sclerotizing 

Opacity — Riband-like  Keratitis    .    , 205 

Ectasies  of  the  Cornea — Staphyloma  Corneas — Conical  Cornea  .    .      211 

Tumors  of  the  Cornea 219 

Injuries  of  the  Cornea — Foreign  Bodies — Losses  of  Substance  .    .      219 
Opacities  of  the  Cornea— Nebula,  Macula,  Leucoma — Sclerotizing 

Opacity — Arcus  Senilis 221 

CHAPTER  IX. 

THE    DISEASES    OF   THE    SCLEROTIC. 

Inflammations  of  the  Sclerotic — Episcleritis — Deep  Scleritis — In- 
juries of  the  Sclerotic — Tumors  of  the  Sclerotic 225 


XU  CONTENTS. 

CHAPTER    X. 

THE    DISEASES    OF   THE    UVEAL   TRACT. 

PAGE 

Iritis — Simple  Plastic  Iritis — Serous  Iritis— Parenchymatous  (in- 
cluding Purulent)  Iritis 230 

Injuries  of  the  Iris — Punctured  Wounds — Foreign  Bodies — Irido- 
dialysis  —  Retroflexion  —  Rupture  of  the  Sphincter  Iridis — 
Traumatic  Aniridia — Anteversion — Traumatic  Mydriasis  .    .    .      240 

New  Growths  of  the  Iris — Cysts — Granuloma — Tubercle — Sarcoma     242 

Congenital  Malformations  of  the  Iris — Heterophthalmos — Corec- 
topia — Polycoria — Persistent  Pupillary  Membrane — Coloboma 
— Irideremia 243 

Operation  on  the  Iris — Iridectomy — Iridotomy 245 

Cyclitis — Plastic  Cyclitis — Serous  Cyclitis — Purulent  Cyclitis— In- 
juries of  the  Ciliary  Body — New  Growths  of  the  Ciliary  Body     247 

Choroiditis — Disseminated  Choroiditis — Syphilitic  Choroido-Retin- 
itis — Central  Senile  Guttate  Choroiditis — Central  Choroiditis — 
Central  Senile  Atrophy  of  the  Choroid — Purulent  Choroiditis 
— Posterior  Sclero-Choroiditis — Detachment  of  the  Choroid  .      250 

Injuries  of  the  Choroid — Foreign  Bodies — Incised  Wounds — Rup- 
ture— New  Growths  of  the  Choroid — Sarcoma — Carcinoma — 
Tubercle  —  Sarcoma  Carcinomatosum — Myosarcoma—  Osteo- 
sarcoma          256 

Congenital  Defects  of  the  Choroid — Coloboma — Albinismus  .    .    .      259 

Sympathetic  Ophthalmitis 260 

CHAPTER   XI. 

THE    MOTIONS    OF   THE    PUPIL    IN    HEALTH   AND    DISEASE. 

The  Size  of  the  Pupil  in  Health — Contraction  of  the  Pupil — Dila- 
tation of  the  Pupil 272 

The  Action  of  the  Mydriatics  and  Myotics  on  the  Pupil 279 

The  Size  of  the  Pupil  in  Disease — Myosis — Mydriasis  ...     •  .    .      280 

CHAPTER  XII. 

GLAUCOMA. 

Primary  Glaucoma — Chronic,  or  Non-Inflammatory,  Glaucoma- 
Acute,  or  Inflammatory,  Glaucoma — Glaucoma  Fulminans — 
Sub-Acute  Glaucoma — Etiology — Pathology — Treatment     .    .      285 

Secondary  Glaucoma — Hemorrhagic  Glaucoma 305 

Congenital  Hydrophthalmos 307 


CONTENTS.  Xlll 

CHAPTER  XIII. 

THE    DISEASES    OF   THE    CRYSTALLINE    LENS. 

PAGE 

Complete  Cataracts — Senile  Cataract — Progress,  Pathogenesis,  and 

Etiology — Treatment 309 

Complete  Cataract  of  Young  People — Diabetic  Cataract — Complete 

Congenital  Cataract 316 

Partial  Cataracts — Central  Lenta!  Cataract — Zonular,  or  Lamellar, 
Cataract — Anterior  Polar,  or  Pyramidal,  Cataract — Fusiform, 
or  Spindle-Shaped,  Cataract 317 

Secondary  Cataract — Posterior  Polar  Cataract — Total   Secondary 

Cataract .    .    .  • 319 

Capsular  Cataract 320 

Traumatic  Cataract     .     • 320 

Operations  for  Cataract — Extraction  of  Cataract — Linear  Extrac- 
tion— The  Modified  Peripheral  Linear  Extraction — The  Three 
Millimetre  Flap  Operation — Cataract  Extraction  without  Iri- 
dectomy         -    •      328 

Discission  or  Dilaceration — Suction  Operation — Secondary  Cataract 

and  its  Operation — Capsulotomy — Iridotomy 346 

Dislocation  of  the  Crystalline  Lens — Lenticouus — Aphakia     ...      351 

CHAPTER  XIV. 

•  THE    DISEASES    OF   THE   VITREOUS    HUMOR. 

Purulent  Inflammation — Other  Inflammatory  AflFections — Opacities 
— Muscse  Volitantes — Fluidity  (Synchysis) — Synchysis  Scintil- 
lans — Foreign  Bodies — Cysticercus — Persistent  Hyaloid  Artery 
— Detachment 355 

CHAPTER  XV. 

THE    DISEASES    OF   THE    RETINA. 

Purulent  Retinitis — Hemorrhagic  Retinitis — Apoplexy  of  the  Re- 
tina— Retinitis  Albuminurica — Retinal  Affections  in  Diabetes — 
Retinitis  Leucsemica — Syphilitic  Retinitis — Quinine  Amaurosis 
— Retinitis  Pigmentosa— Retinitis  Punctata  Albescens — De- 
velopment of  Connective  Tissue  in  the  Retina— Detachment 
of  the  Retina — Cysticercus  under  the  Retina— Aneurism  of  the 
Central  Artery  of  the  Retina — Embolism  of  the  Central  Artery 
of  the  Retina — Thrombosis  of  the  Central  Artery  of  the  Retina 
— Glioma  of  the  Retina— Blinding  of  the  Retina  by  Direct  Sun- 
light— Neurasthenic  Asthenopia,  or  Retinal  Anaesthesia — Trau- 


XIV  CONTENTS. 

PAGE 

matic  Anaesthesia  of  the  Retina — Commotio  Retinae,  or  Trau- 
matic (Edema  of  the  Retina — Hyperesthesia  of  the  Retina  .    .      365 

CHAPTER  XVI. 

THE    DISEASES    OF   THE    OPTIC    NERVE. 

Optic  Neuritis  (Papillitis),  due  to  : — Cerebral  Tumors — Tubercular 
Meningitis — Acute  Myelitis — Hydrocephalus — Tumors  of  the 
Orbit — Inflammatory  Processes  in  the  Orbit — Exposure  to  Cold — 
Suppression  of  Menstruation — Chlorosis — Syphilis — Rheuma- 
tism— Lead  Poisoning — Multiple  Sclerosis — and  to  Hereditary, 
and  Congenital,  Predisposition 389 

Chronic  Retro-bulbar  Neuritis,  or  Central  Amblyopia  (Toxic  Ambly- 
opia)— Optic  Neuritis  Associated  with  Persistent  Dropping  of 
Watery  Fluid  from  the  Nostril 395 

Atrophy  of  the  Optic  Nerve,  due  to  : — Optic  Neuritis — Pressure — 
Embolism  of  the  Central  Artery  of  the  Retina — Syphilitic  Re- 
tinitis, Retinitis  Pigmentosa,  Choroido-Retinitis,  and  to  Dis- 
ease of  the  Spinal  Cord  (Spinal  Amaurosis) — Optic  Atrophy  as 
a  Purely  Local  Disease 399 

Tumors  of  the  Optic  Nerve— Hyaline,  or  Colloid,  Outgrowths- 
Injuries  of  the  Optic  Nerve 402 

Glycosuric  Amblyopia — Amblyopia  due  to  Hemorrhages  from  the 

Stomach,  Bowels,  or  Uterus 403 

CHAPTER  XVII. 

AMBLYOPIA  AND  AMAUROSIS  DUE  TO  CENTRAL  AND  OTHER  CAUSES. 

Hemianopsia — Arrangement  of  the  Cortical  Visual  Centres,  their 
Relations  to  the  Retina,  and  the  Course  of  the  Optic  Fibres 
between  these  two  points  —  Localization  of  the  Lesion  in 
Hemianopsia  —  Alexia,  or  Word-Blindness  —  Dyslexia — Soul- 
Blindness,  Psychical  Blindness,  or  Mind-Blindness — Congenital 
Amblyopia — Reflex  Amblyopia — Hysterical  Amblyopia — Nyc- 
talopia —  Uraemic  Amblyopia  —  Snow-Blindness  —  Pretended 
Amaurosis — Erythropsia 407 

CHAPTER  XVIII. 

THE    MOTIONS    OF    THE    EYEBALLS    AND    THEIR    DERANGEMENTS. 

Actions  of  the  Orbital  Muscles — Inclination  of  the  Vertical  Meri- 
dian in  the  Several  Principal  Positions — Muscles  called  into 
Action  in  the  Several  Principal  Positions 424 


CONTENTS.  XV 

PAGE 

Paralysis  of  the  Orbital  Muscles— General  Symptoms — Paralysis 
of  the  External  Rectus — Paralysis  of  the  Superior  Oblique — 
Paralysis  of  the  Internal  Rectus,  Superior  Rectus,  Inferior 
Oblique  and  Levator  Palpebise— Ophthalmoplegia  Externa,  or 
Nuclear  Paralysis — Cerebral  Paralysis  of  Orbital  Muscles — The 
Localizing  Value  of  Paralyses  of  Orbital  Muscle  in  Cerebral 
Disease 429 

Convergent  Concomitant  Strabismus — Causes — Single  Vision  in — 
Amblyopia  of  Squinting  Eye-  Clinical  Varieties  of — Measure- 
ment of — Mobility  of  Eye  in — Treatment — Orthoptic  Treat- 
ment—  Operative  Treatment  —  Tenotomy  —  Advancement  of 
External  Rectus — Dangers  of  the  Strabismus  Operation  — 
Treatment  Subsequent  to  Operation 453 

Insufficiency  of  the  Internal  Recti,  and  Divergent  Concomitant 
Strabismus  —  Muscular  Asthenopia  —  Treatment  —  Operative 
Treatment 477 

Nystagmus 483 

CHAPTER  XIX. 

THE    DISEASES    OF   THE    ORBIT. 

Orbital  Cellulitis — Periostitis  of  the  Orbit — Caries  of  the  Orbit — 
Injuriesof  the  Orbit — Tumors  of  the  Orbit — Diseases  of  Neigh- 
boring Cavities — Hernia  Cerebri — Exophthalmic  Goitre  .    .    .      484 

Appendix  I. — Holmgren's  Method  for  Testing  the  Color-Sense  .    .      499 

Appendix  II. — Regulations  as  to  Defects  of  Vision  which  Disqualify 
Candidates  for  Admission  into  Civil,  Naval  and  Military  Ser- 
vices, the  Royal  Irish  Constabulary,  and  the  Mercantile 
Marine 502 

Index 607 


TO   THE  STUDENT. 


You  should  read  carefully  Chapters  I,  IT,  and  III,  omitting  at  first 
the  small  print,  either  before,  or  immediately  on,  joining  the  Ophthal- 
mic Hospital,  or  Department. 

n.  R    S. 


DISEASES   OF  THE    EYE. 


CHAPTER  I. 


Some  Elementary  Optics — Numbering  of  Trial- Lenses  and  Spectacle 
Glasses — Normal  Refraction  and  Accommodation — The  Metre  Angle 
—The  Angle  Gamma— The  Sense  of  Sight  (Light-Sense,  Color- 
Sense,  Form-Sense) — The  Field  of  Vision. 

SOME    ELEMENTARY    OPTICS. 

Refraction. — The  light  emitted  by  a  luminous  point  is  propa- 
gated in  all  directions  in  straight  lines,  which  are  called  "  rays." 

A  ray  of  light,  passing  from  one  medium  into  another  of 
different  density,  becomes  deviated  in  its  path,  and  is  said  to  be 
"  refracted."  The  phenomenon  itself  is  called  "  refraction."  A 
ray  of  light  (a  h,  Fig.  ] )  falling  on  ^^^^  -^ 

a  prism  (Pj  undergoes  refraction 
in  its  passage  through  it  (  5  c), 
and  again  on  its  exit  at  the  oppo- 
site side  (c  cOj  JD  each  instance  the 
deviation  being  toward  the  base 
of  the  prism.  An  observer  who  is 
placed  at  d,  so  as  to  receive  into 
his  eye  the  emerging  ray,  j^rojects,  or  thinks  he  sees,  at  a',  in  a 
prolongation  of  d  c,  the  object  from  which  the  ray  comes; 
that  is,  displaced  toward  the  apex  of  the  prism. 

The  deflection  which  a  ray  undergoes  by  passing  through  a 
prism  increases  with  the  size  of  the  angle  at  the  apex  of  the 
latter.  Prisms  are  described  as  being  of  1°,  2°,  3°,  etc.,  accord- 
ing to  the  size  of  this  apex,  or  refracting  angle.* 

*  It  has   been   proposed  to  measure  prisms  for   ophthalmic  practice 

1 


DISEASES   OF   THE   EYE. 


Fig.  2. 


Convex  and  concave  lenses  may  be  regarded  as  being  com- 
posed of  prisms :  convex  lenses  of  prisms  placed  with 
their  bases  together  (Fig.  2,  A)  ;  con- 
cave lenses  of  prisms  with  their  edges 
together  (Fig.  2,  B).  Consequently,  con- 
vex lenses  cause  pencils  of  rays  which 
pass  through  them  to  converge,  while 
concave  lenses  produce  divergence  of  the 
rays. 

The  Principal  Axis  of  a  lens  is  a  line 
(P  F,  Fig.  3)  passing  through  the  centres 
of  curvature  of  both  its  surfaces. 
The  Optical  Centre  of  a  lens  is  a  point  through  which  the 
rays  must  pass  in  order  that  they  may  not  undergo  deviation.* 


Fig.  3. 


Any  rays  passing  through  the  optical  centre,  except  the  prin- 
cipal ray  or  axis,  are  called  Secondary  Rays. 

All  the  other  rays  of  the  pencil  undergo  refraction. 

Convex  Lenses  (Fig.  3)  bring  parallel  rays  of    light  (a  b  P  c 


either  according  to  their  angle  of  minimum  deviation,  by  prism-dioptries, 
or  by  metre-angles,  but  none  of  these  methods  seem  to  be  free  from 
objection,  or  to  offer  any  marked  advantage  over  the  current  method. 

*  Although  sufficient  for  practical  purposes,  this  is  not  theoretically 
correct,  as  all  secondary  rays  passing  through  the  optical  centre  are 
slightly  deviated,  but  remain  parallel  to  their  original  direction.  Strictly 
speaking,  the  principal  axis  is  the  only  one  which  undergoes  no  deviation. 


SOME    ELEMENTARY    OPTICS.  3 

c/,  Fig.  3)  passing  through  them  to  a  focus  at  a  point  (F)  sl  cer- 
tain distance  on  the  other  side.  This  point  is  called  the  Principal 
Focus  of  the  lens,  and  the  distance  from  it  to  the  lens  is  termed 
the  Focal  Length  of  the  lens.  The  more  curved  the  surface  of 
the  lens,  the  shorter  will  be  its  focal  length,  and  the  more  "  pow- 
erful "  the    lens.     Rays   diverging  from  a  light  placed  at  F, 

Fig.  4. 


and  falling  on  the  lens,  are  made  parallel  when  they  reach  its 
other  side. 

Divergent  rays,  /.  e.,  those  coming  from  a  near  object  (such 
as  0,  Fig.  4),  do  not  meet  at  the  principal  focus  of  the  lens,  but 
at  a  point  (F')  beyond  it.  This  latter  point  is  further  from  the 
lens  the  nearer  0  is  to  the  principal  focus,  F,  until,  when  0 
reaches  F,  F'  becomes  infinitely  distant,  and  then  the  rays, 
after  passing  through  the  lens,  are  parallel.     In  like  manner, 

Fig.  5. 


rays  from  F'  would  focus  at  0,  and  hence  these  two  points  are 
termed  Conjugate  Foci. 

If  the  point  (  0,  Fig.  5)  from  which  the  rays  come  be  nearer 


4  DISEASES   OF    THE    EYE. 

the  lens  than  its  principal  focus  (F),  they  will  not  be  made 
convergent  or  even  parallel  by  the  lens,  but  will  remain 
divergent,  although  not  so  much  so  as  before  their  entrance  into 
the  lens.  If  we  imagine  those  still  divergent  rays  to  be  pro- 
longed backward,  they  would  meet  at  F,  which  would  be  called 
the  Virtual  Focus.*    0  and  Fare  also  conjugate  foci,  and  hence 

Fig.  6. 


rays  converging  toward  F  from  the  other  side  of  the  lens  will 
be  united  by  the  lens  at  0. 

A  Concave  Lens  (Z,  Fig.  6)  makes  parallel  rays  of  light 
(a  b  c  d  e)  divergent  on  passing  through  it;  and  if  the  direction 
of  the  divergent  rays  be  prolonged  backward,  they  meet  at  a 

Fig.  7. 


focus  (jP),  which  is  therefore  virtual,  although  it  is  the  principal 

*It  is  called  "  virtual,"  because  there  is  no  real  convergence  of  the 
rays  at  that  point ;  but  to  an  observer  placed  on  the  other  side  of  the 
lens  (i),  into  whose  eyes  the  rays  fall,  they  would  seem  to  come  from 
that  point. 


SOME   ELEMENTARY   OPTICS.  5 

focus  of  the  lens.     In  the  case  of  concave  lenses,  then,  there  are 
only  virtual  foci. 

When  we  speak  of  the  imacje  formed  by  a  lens,  we  mean 
the  collection  of  foci  produced  by  it,  of  pencils  of  rays  coming 
from  the  various  points  of  an  object.  For  example :  '\i  0  B 
(Fig.  7)  be  the  object,  and  a  pencil  of  rays  pass  from  its  upper 
end,  0,  through  the  convex  lens,  L,  they  will  be  united  again  at 
O  on  the  secondary  axis,  0  0' ,  and  will  form  there  an  image  of 
the  point  from  which  they  come ;  while  the  rays  from  B  will 
form  an  image  of  that  point  at  B'  on  the  secondary  axis,  B  B' . 
Similarly,  images  of  all  the  points  between  0  and  B  are  formed 

Fig.  8. 


between  O  and  B' .  Hence,  the  real  images*  formed  by  convex 
lenses  are  inverted. 

But  if  the  object  be  at  the  principal  focus  of  the  lens  (at  F, 
Fig.  3),  the  rays  on  emerging  at  the  opposite  side  are  made  par- 
allel, and  the  image  is  formed  at  an  infinite  distance. 

If  the  object  be  nearer  the  lens  (at  0,  Fig.  5)  than  the  prin- 
cipal focus  (i^),  the  image  will  be  an  erect  enlarged  virtual  one 
(at  V)  on  the  same  side  as  the  object. 

With  concave  lenses  the  images  are  virtual  and  smaller  than 
the  object.  In  Fig.  8  the  large  arrow  is  the  object,  and  F  the 
principal  focus  of  the  lens.     Rays  passing  through  the  lens  from 

*They  are  called  "  real  "  images  because  they  have  a  real  existence, 
and  can,  in  fact,  be  caught  upon  a  screen. 


DISEASES   OF   THE    EYE. 


the  large  arrow  are  made  more  divergent,  and  the  image  seems 
to  be  at  a  point  (d  e)  found  by  prolongation  backward  of  the 
direction  of  those  rays  after  refraction. 

It  will  be  convenient  for  the  reader  that  I  should  here  describe 
the  method  in  use  for — 

The  Numbering  of  the  Trial-Lenses. — The  lenses  in  trial-cases 
and  in  spectacles  are  numbered  according  to  the  metrical  system. 
The  lens  of  one  metre  (39*  inches)  focal  length  is  called  the 
Dioptric  Unit,  or  the  Dioptry  (1  D),  of  the  metrical  system.  2 
D,  3  D,  4  D,  etc.,  indicate  the  number  of  metre  lenses,  or  diop- 
trics, contained  in  each  of  these  lenses.  2  D  is  therefore  twice 
as  powerful  a  lens  (its  focal  length  only  half  as  long)  as  1  D. 

Convex  lenses  are  indicated  by  the  -}-  sign  placed  before  their 
number,  thus,  -f  5  D ;  and  concave  lenses  by  the  —  sign,  thus, 
—  5  D. 

If  it  be  required  to  ascertain  the  focal  length  of  a  given  lens, 
divide  100  (1  metre  =  100  centimetres)  by  the  number  of  the 
lens,  and  the  answer  will  give  the  focal  length  in  centimetres. 
For  example,  the  focal  length  of  10  D  is  \y-  =  10  cm. 

If  the  focal  length  of  the  lens  be  known,  and  it  be  desired  to 
ascertain  its  dioptric  number,  we  find  it  by  dividing  100  cm.  by 
the  focal  length.     For  example,  if  the  focal  length  be  33  cm., 
3D. 
Reflection. — When  a  ray  of  light  meets  a  polished  surface,  it 

rebounds  from  it,  or  is  "  re- 
flected "  by  it,  changing 
its  direction,  and  the  phe- 
nomenon is  termed  Reflec- 
tion. 

The  images  formed  in 
plane  mirrors  are  upright 
and  virtual.  If  0  B  (Fig. 
9)  be  the  object,  rays  pass 
from  it  to  the  mirror,  31, 
and  are  reflected.  Some  of  the  reflected  rays  reach  the  eye  of 
the  observer,  and  there  seems  to  him  to  be  an  upright  image  of 


then  -V>/ 


Fig.  9. 


NORMAL   REFRACTION   AND   ACCOMMODATION.  7 

0  B  formed  at  O  B  behind  the  mirror  in  a  prolongation  of 
the  reflected  rays. 

The  images  formed  by  concave  spherical  mirrors  are  inverted 
and  real,  provided  the  object  be  beyond  the  principal  focus  of 
the  mirror.*  For  example,  \i  0  B  (Fig.  10)  be  the  object,  and 
M  the  mirror,  the  rays  0  A  and  0  C,  coming  from  0,  will  be 
reflected  so  as  to  meet  at  0',  and  the  rays  B  E  and  B  D,  coming 

Fig.  10. 


from  B,  will  be  reflected  to  B',  and  thus  form  a  real  inverted 
image,  B'  0',  in  front  of  the  mirror. 

NORMAL  REFRACTION  AND  ACCOMMODATION. 

The  eye  is  a  dark  chamber,  containing  a  series  of  convex  re- 
fracting surfaces,  namely,  the  cornea  and  the  anterior  and 
posterior  surfaces  of  the  crystalline  lens  ;  and  certain  "  intra- 
ocular media,"  namely,  the  aqueous   humor,  the  substance  of 


^As  this  is  always  the  case  in  practical  ophthalmoscopy — the  source  of 
light  being  always  beyond  the  focus  of  the  ophthalmoscopic  mirror — it  is 
the  only  condition  considered  here. 


8  DISEASES    OF    THE    EYE. 

the  crystalline  lens,  and  the  vitreous  humor.  By  aid  of  this 
apparatus,  which  is  called  "  the  dioptric  system  of  the  eye," 
distinct  inverted  images  of  external  objects  are  formed  on  the 
retina. 

The  refracting  media  are  centred  on  the  optical  axis  (0  A, 
Fig.  11),  a  line  which,  passing  through  the  optical  centre  (N)  of 
the  eye,  meets  the  retina  at  a  point  (^)  slightly  to  the  inner  side 
of  the  macula  lutea  (J/). 

In  treating  of  the  eye  we  have  to  consider  two  sets  of  visual 
objects,  viz.,  distant  objects  and  near  objects.  Distant  objects 
are  those  at  6  metres  and  more  from  the  eye  ;  near  objects  are 
those  closer  to  the  eye  than  6  metres.     For  practical  purposes, 

Fig.  11. 


the  rays  which  pass  through  the  pupil,  coming  from  any  given 
point  of  a  distant  object,  are  as  good  as  parallel,  their  divergence 
being  so  very  slight  w^hen  they  reach  the  eye,  and  we  regard 
them  as  being  parallel. 

Refraction. — By  the  Refraction  of  the  Eye  is  meant  the 
faculty  it  has  ivhen  at  rest  (i.e.,  without  an  effort  of  accommoda- 
tion) of  altering  the  direction  of  rays  of  light  which  pass  into 
it,  making  parallel  rays  convergent,  and  divergent  rays  less 
divergent. 

In  Normal  Refraction,  or  Emmetropia  (k'/irisTpo-:  an^>),  as  it  is 
termed,  parallel  rays  (see  Fig.  12,  in  which  the  object  from 
which  the  rays  come  is  supposed  to  be  6  metres  or  more  from 
the  eye)  in  passing  through  the  dioptric  media  are  given  such  a 
convergence  that  they  are  brought  to  a  focus  on  the  layer  of 


NORMAL   REFRACTION   AND   ACCOMMODATION.  9 

rods  and  cones  of  the  retina,  and  form  there  a  distinct  inverted 
image  of  the  point  or  object  from  which  they  come.  In  other 
words,  the  retina  is  placed  at  the  principal  focus  of  the  dioptric 
system  of  the  eye,  which  is  thus  adapted  for  parallel  rays,  and 
its  "  far  point "  (vide  infra)  is  at  infinity. 

Fig.  12. 


Accommodation. — But  the  eye  can  see  near  objects  distinctly 
as  well  as  distant  objects,  although  the  rays  from  any  given 
point  (a,  Fig.  13)  of  a  near  object  reach  the  eye  with  a  divergence 
so  considerable  that  they  could  not  be  brought  to  a  focus  on  the 
retina  by  the  unaided  refraction,  but  would  converge  toward  a 


Fig.  13. 


point  (  their  conjugate  focus  a')  behind  the  retina,  and  would  not 
form  a  distinct  image  on  the  latter,  but  merely  a  blurred  image 
or  circle  of  diffusion  (at  5  c).  It  is  obvious,  therefore,  that  an 
increase  of  refracting  power  in  the  eye  is  necessary,  in  order 
that  near  objects  may  be  distinctly  seen.     It  is  this  increase  in 


10  DISEASES   OF   THE   EYE. 

the  refracting  power  for  the  purpose  of   near  vision  which  is 
called  Accommodation. 

The  Mechanism  of  Accommodation  is  as  follows  : — The  ciliary 
muscle  (771,  Fig.  14)  contracts,  thus  drawing  forward  the  choroid 
and  ciliary  processes,  and  relaxing  the  zonula  of  Zinn  (2),  which 
is  attached  to  the  latter.  The  lens  (0,  which  was  flattened  by 
the  tension  of  the  zonula,  is  now  free  to  assume  a  more  spherical 
shape,  in  response  to  its  own  elasticity.  The  posterior  surface 
of  the  lens  scarcely  alters  in  shape,  being  fixed  in  the  patellary 

Fig.  14. 


c,  cornea  ;  a,  anterior  chamber;  I,  lens;  v,  vitreous  humor:  i,  iris;  z,  zonula  of  Zinn; 
m,  ciliary  muscle. 

fossa,  but  the  anterior  surface  becomes  more  convex,  thus  increas- 
ing its  refracting  power.  Associated  with  the  act  of  accommoda- 
tion is  a  contraction  of  the  pupil.  The  accompanying  figure  (Fig. 
14)  represents  the  changes  which  take  place  in  accommodation, 
the  dotted  lines  indicating  the  latter  state. 

The  Far  Point,  and  the  Near  Point.— It  is  possible  for  the  eye 
to  see  objects  accurately  at  every  distance,  from  its  Far  Point, 
i.  e.,  its  most  distant  point  of  distinct  vision  (Functum  Remotum, 
— R.),  up  to  a  point  only  a  few  centimetres  from  the  eye,  called 
the  Near  Point  (Punctum  Proximum, — P.).     AYe  can  find  the 


NORMAL   REFRACTION   AND   ACCOMMODATION.  11 

latter  by  directing  the  patient  to  look  at  a  page  printed  in  small 
type,  and  by  bringing  it  slowly  closer  and  closer  to  his  eye,  until 
a  point  is  reached  where  he  cannot  distinguish  the  words  and 
letters,  which  become  blurred.  A  point  very  slightly  more 
removed  from  the  eye  than  this,  where  he  can  read  distinclly, 
is  the  near  point.  Between  the  near  point  and  the  eye  vision  is 
indistinct,  because  no  effort  of  the  ciliary  muscle  can  produce 
the  amount  of  convexity  of  the  lens  required  for  so  short  a  dis- 
tance. 

The  Amplitude  of  Accommodation. — This  is  the  amount  of 
accommodative  effort  of  which  the  eye  is  capable,  i.  e.,  the  effort 
it  makes  in  order  to  adapt  itself  from  its  far  point  up  to  its  near 
point.    The  amplitude  of  accommodation  (a),  therefore,  is  equal 

Fig.  15. 


to  the  difference  in  the  refracting  power  of  the  eye  at  rest  (r) 
and  when  its  accommodation  is  exerted  to  the  utmost  (p),  as 
expressed  by  the  formula  a  =  p  —  r.  It  may  be  represented 
by  that  convex  lens  placed  close  in  front  of  the  eye,  which 
would  take  the  place  of  the  increased  convexity  of  the  lens,  or, 
in  other  words,  which  would  give  to  rays  coming  from  the  near- 
est point  of  distinct  vision  a  direction  as  if  they  came  from  the 
far  point.  The  number  of  this  lens  expresses  the  amplitude  of 
accommodation  in  a  given  eye. 

For  example: — if,  in  an  emmetropic  eye  (^E,  Fig.  15),  the 
near  point  be  situated  at  20  cm.,  then  a  convex  lens  (X)  of  20 
cm.  focal  length  placed  close  to  the  eye  (between  that  point 
and  the  eye)  would  give  to  rays  coming  from  the  near  point  a 
direction  (i.  e.,  would  make  them  parallel)  as  though  they  came 


12  DISEASES   OF   THE   EYE. 

from  a  distant  object,  and  this  normally  refracting  eye  would 
then  be  enabled,  by  aid  of  its  refraction  alone,  to  bring  these 
rays  to  a  focus  on  the  retina.  Making  use  of  the  above  equa- 
tion, we  find  in  this  case — since  a  focal  length  of  20  cm.  repre- 
sents a  lens  of  5  D — that  a  =  5  —  r,  but  R  being  situated  at  in- 
finity, we  designate  it  by  the  sign  qo  ;  hence,  r  =  ~^  =  —  =  0  ; 
therefore  a  =  5  —  0  =  5  D*  ^         ^ 

The  amount  of  amplitude  of  accommodation  (/.  e.,  the  number 
of  the  lens  which  would  represent  it)  is  the  same  in  every  kind 
of  refraction,  according  to  the  age  of  the  individual,  but  in  em- 
metropia  alone  is  a  =  p  as  above,  because  in  it  alone  is  r  =  0. 

Under  the  head  of  "Anomalies  of  Accommodation,"  Chapter 
II,  will  be  found  Professor  Bonder's  diagram  representing  the 
amplitude  of  accommodation  at  difl^erent  ages. 

Connection  between  Accommodation  and  Convergence  (Rela- 
tive Accommodation). — With  every  degree  of  convergence  of 
the  visual  lines  a  certain  effort  of  accommodation  is  associated. t 
Thus,  if  the  object  be  situated  2  metres  from  the  eye,  the  visual 
lines  converge  to  that  point,  and  a  certain  effort  of  accommoda- 
tion is  made.  But  this  connection  between  accommodation  and 
convergence  is  somewhat  elastic,  for  the  accommodative  effort 
may  be  increased  or  decreased,  while  the  object  is  kept  distinctly 
in  view,  and  the  same  convergence  maintained.     That  it  may  be 

*  It  must  be  observed  that  R  represents  the  distance  of  the  Far  Point 
from  the  eye,  while  r  represents  the  refractive  power  which  is  added  to  the 
eye  by  accommodation  or  by  a  lens,  in  order  to  adapt  it  for  the  distance  R. 

Hence,  it  is  evident  that  r  ==  ^  ,  because  the  strength,  or  refractive  power,of 

a  lens  is  inversely  as  its  focal  length,  e.  g.,  a  lens  of  the  strength  of  4  D  will 

Im.       100  cm. 
haveafocallength  of  |  that  of  a  lens  of  1  D,  i.e.,  ^7—  =  — r —  =  0.25  cm. 

(see  above,  numbering  of  Trial-Lenses).  Similarly,  j9=    p~  and  a  ==.    ;  P 

representing  the  distance  of  the  Near  Point,  and  A  the  focal  length  of 
the  lens  which  represents  the  Accommodation. 

t  A  common  centre  in  the  brain  governs  these  motions  and  contraction 
of  the  pupil. 


NORMAL   REFRACTION   AND   ACCOMMODATION. 


13 


Fig.  16. 


increased  is  shown  by  the  experiment  of  placing  a  weak  con- 
cave glass  before  the  eye,  when  it  will  be  found  that  the  object 
is  still  distinctly  seen.  And  if  a  weak  convex  glass  be  then 
held  before  the  eye,  the  object  will  also  be  clearly  seen,  showing 
that  the  accommodative  effort  may  be  lessened,  without  affecting 
vision  or  convergence.  This  amplitude  of  accommodation  for  a 
given  point  of  convergence  of  the  visual  lines,  found  by  the 
strongest  concave  and  strongest  convex  glasses  with  which  the 
object  can  still  be  distinctly  seen,  is  called  the  Relative  Ampli- 
tude of  Accommodation.  That  part  of  it  which  is  already  in 
use,  and  is  represented  by  the  convex  lens,  is  termed  the  negative 
part;  while  the  positive  part  is  represented  by  the  concave  lens, 
and  has  not  been  brought  into  play.  For 
sustained  accommodation  at  any  distance 
it  is  necessary  that  the  positive  part  of 
the  relative  amplitude  of  accommodation 
be  considerable  in  amount. 

Moreover,  the  convergence  may  be 
altered,  while  the  same  effort  of  accom- 
modation is  maintained,  as  is  shown  by 
the  experiment  of  placing  a  weak  prism 
with  its  base  inward  before  one  eye. 
In  order  that  the  object  may  then  be 
seen  singly,  it  will  be  necessary  for  the  eye 
before  which  the  prism  is  placed  to  rotate 
somewhat  outward,  and  it  will  be  found 
that  the  individual  can  do  this  while  at 
the  same  time  he  sees  the  object  with  the 
same  distinctness,  showing  that  the  same 
effort  of  accommodation  has  been  main- 
tained, although  the  angle  of  convergence 
of  the  visual  axis  is  less  than  before. 

The  Metre  Angle. 
If  the  visual  Hne  (^1,  Fig.  16)  of  an  eye  E  have  to  be  brought  to  bear 
on  a  point  (1,  Fig.  16)  1  metre  distant  from  it  in  the  median  line  (i/"l), 
the  angle  of  convergence  {E\  M)  which  the  visual  line  thus  makes  with 


14 


DISEASES   OF   THE   EYE. 


the  median  line  is  called  the  Metre  Angle.  It  expresses  the  degree  of 
convergence  necessary  for  binocular  vision  at  that  distance,  and  is  em- 
ployed as  the  unit  for  expressing  other  degrees  of  convergence.  If,  for 
example,  an  object  be  situated  ^  a  metre  (^,  Fig.  16)  from  the  eye,  the 
angle  of  convergence  {E  'hM)  must  be  practically  twice  as  large  as  at  1 
metre  :  C.  (Convergence)  —2  metre  angles.  If  the  object  be  only  f  of  a 
metre  distant,  3  metre  angles  are  required  :  C.  =  3  metre  angles.  If 
the  object  be  situated  2  metres  from  the  eye,  the  angle  of  convergence 
will  be  only  one-half  as  great  as  at  1  metre,  and  here  C.  =  ^  metre 
angle  ;  while  if  the  eye  be  directed  toward  a  distant  object  [D),  there 
will  be  no  angle  of  convergence,  and  if  the  visual  lines  be  divergent  the 

metre  angle  will  be  negative. 
YiG.  17.  Now,  the  average  normal  emmetropic 

eye  requires,  for  each  distance  of  binoc- 
ular vision,  as  many  metre  angles  of 
convergence  as  it  requires  dioptrics  of 
accommodation.  For  a  distance  of  1 
metre  an  effort  of  accommodation  of 
1  dioptry  is  required,  and  also  1  metre 
angle  of  convergence  ;  at  |  metre  from 
the  eye  3  D  of  accommodation  and  3 
metre  angles,  and  so  on  ;  while  for  dis- 
tant objects  neither  angle  of  conver- 
gence nor  effort  of  accommodation  is 
required. 

The  Angle  Gamma. 
The  Optic  Axis  is  an  imaginary  line 
{P^  P,  Fig.  17)  which  passes  through 
the  centre  (C)  of  the  cornea  and  the 
posterior  pole  (P)  of  the  globe,  i.  e.,  a 
point  situated  between  the  macula  lutea 
(M)  and  the  optic  papilla  (Z>).  2'he 
Visual  Line  {MO)  unites  the  point  of 
fixation  (0) — the  object  looked  at — 
with  the  macula  lutea.  It  does  not  coin- 
cide with  the  optic  axis,  but  crosses  it 
at  the  principal  optic  centre  {K)  of  the 
eye.  The  Line  of  Fixation  {R  0)  joins 
the  centre  of  rotation  {R)  of  the  eye 
with  the  point  of  fixation.  The  Angle  y  is  the  angle  0  R  P^  formed  at 
the  centre  of  rotation  by  the  optic  axis  and  the  line  of  fixation. 


THE   SENSE   OF   SIGHT.  15 

The  line  of  fixation  and  the  visual  line  so  nearly  coincide  that  in 
practice  we  regard  them  as  identical ;  and  hence,  in  practice  the  angle  7 
is  the  angle  0  K  P\  It  should  not  be  confounded,  as  is  often  the  case, 
with  The  Angle  Alpha,  which  is  the  angle  0  K  C^  formed  at  the  nodal 
point  by  the  visual  line  and  the  major  axis  (C^  K)  of  the  corneal 
ellipse.  This  axis  rarely  passes  through  the  centre  of  the  cornea  ;  but  as 
it  never  lies  far  from  the  latter,  the  difference  in  dimension  between  the 
two  angles  is  very  slight. 

In  order  to  measure  the  angle  y,  the  eye  is  placed  at  the  perimeter  as 
for  an  examination  of  its  field  of  vision.  By  means  of  the  corneal 
reflection  of  a  candle-flame,  which  latter  is  moved  along  the  arc  of  the 
perimeter,  the  centre  of  the  cornea  is  found.  The  position  of  the  flame 
at  the  perimeter  then  gives  the  angle  7.  The  average  size  of  the  angle  } 
is  5°. 

THE  SENSE  OF  SIGHT. 

The  Sense  of  Sight  consists  of  three  Visual  Perceptions  or  Sub- 
Senses  ;  namely,  the  Light-Sense,  the  Color-Sense,  and  the  Form- 
Sense.     (See  Chap.  XYII.) 

The  Light-Sense  is  the  power  the  retina,  or  the  visual  centre, 
has  of  perceiving  gradations  in  the  intensity  of  illumination. 
The  most  convenient  clinical  method  of  testing  the  light-sense 
seems  to  be  the  photometer*  invented  by  Messrs.  Izard  and 
Chibret.  On  looking  through  this  instrument  toward  the  sky 
two  equally  bright  discs  are  seen.  By  a  simple  mechanism  one 
of  the  discs  can  be  made  darker.  If  the  eye  does  not  perceive 
the  diflference  in  illumination  between  the  two  discs  within  5°, 
its  light-sense  is  abnormal ;  or  we  may  say  its  L.  D.  (Light  Dif- 
ference) is  too  high.  Again,  if  one  disc  be  made  quite  dark, 
and  be  then  gradually  lighted,  the  patient  is  required  to  indicate 
the  smallest  degree  of  light,  or  L.  M.  (Light  Minimum),  by 
which  he  can  observe  the  disc  issuing  from  the  darkness.  This 
should  not  be  more  than  1°  or  2°. 

In  practical  ophthalmology  the  light-sense  is  not  yet  of  much 
interest ;  but  it  is  stated  that  diseases  primarily  involving  the 
nervous  elements  in  the  optic  nerve  show  a  tendency  to  defective 

*  To  be  had  of  Roulot,  Paris. 


16  UISEASES   OF   THE   EYE. 

L.  D. ;  while  diseases  primarily  involving  the  choroid  and  retina 
cause  defective  L.  M."^ 

The  Color-Sense  is  the  power  the  eye  has  of  distinguishing 
light  of  different  wave-lengths.  According  to  the  Young-Helm- 
holtz  theory  the  retina  possesses  three  sets  of  color-perceiving 
elements,  those  for  Red,  Green,  and  Blue  or  Violet.  These  are 
termed  primary  colors,  all  other  colors  being  compounds  of  them. 

According  to  Bering's  theory  the  color-sense  and  the  light- 
sense  depend  upon  chemical  changes  in  the  retina,  or  in  the 
"  visual  substances "  situated  in  the  retina.  He  suggests  the 
existence  of  three  different  visual  substances,  the  white-black, 
the  red-green,  and  the  blue-yellow,  by  the  using  up  or  "  Dis- 
similation," and  restoration  or  "  Assimilation,"  of  which  sub- 
stances the  sensations  of  light  and  color  are  produced.  In  the 
case  of  the  white-black  substance  the  sensation  of  white,  or  of 
light,  corresponds  to  the  process  of  dissimilation  ;  while  the  sen- 
sation of  black,  or  of  darkness,  corresponds  to  the  process  of 
assimilation.  For  the  red-green  and  blue-yellow  substances  it 
cannot  be  said  which  color-sensation  implies  assimilation,  and 
which  dissimilation.  The  members  of  the  black-white  pair  can 
mingle  with  each  other  and  with  those  of  the  other  tw^o  pairs; 
but  the  respective  members  of  the  two  color  pairs  (being  "  con- 
trast colors  "),  e.  g.  blue  and  yellow,  cannot  unite  with  each 
other. 

In  testing  the  color-sense  the  spectral  colors  are  the  best  for 
exact  experiments,  but  the  difficulty  of  producing  them  at  every 
moment,  and  of  combining  them,  renders  them  of  little  clinical 
use. 

*  The  Light-Sense  and  the  Adaptation  of  the  Retina,  although  related 
functions,  must  not  be  confounded  one  with  the  other.  By  the  latter  is 
meant  the  power  the  retina  has  of  gradually  adapting  itself  to  see  when 
the  individual  passes  from  a  bright  into  a  dim  light.  When  it  cannot  do 
this  with  normal  rapidity,  or  to  a  normal  degree,  the  symptom  called 
night-blindness  results.  It  is  quite  possible  for  the  light-sense  to  be 
normal,  and  yet  for  the  retinal  adaptation  to  be  very  defective,  and  vice 
versa. 


THE   SENSE   OF   SIGHT.  17 

The  clinical  method  commonly  employed  for  testing  the  color- 
sense  is  that  of  Professor  Holmgren,  of  Upsala,  which  is  based 
upon  the  Young-Helmholtz  theory.  The  test-objects  used  are 
colored  wools,  of  which  a  large  number  of  skeins  of  every  hue 
are  thrown  together. 

Test  I  (vide  inside  of  end  cover)  consists  in  presenting  to  the 
individual,  in  good  diffused  daylight,  a  pale  but  pure  green 
sample,  and  requiring  him  to  select  out  of  the  bundle  of  wools 
of  all  colors  before  him  all  of  those  samples  which  seem  to  him 
to  correspond  to  the  test  sample.  If  he  do  this  correctly,  it  is 
unnecessary  to  proceed  further;  the  individual  has  normal  color- 
sense.  Among  the  skeins,  however,  there  are  some  which  are 
termed  colors  of  confusion  (grays,  buffs,  straw-color,  etc.) ;  and 
if  he  select  one,  or  several,  of  these,  he  is  color-blind. 

If,  now,  we  want  to  ascertain  the  kind  and  degree  of  his 
defect,  we  proceed  to  Test  Ha.  A  pink  (mixture  of  blue  and 
red)  skein  is  given  to  be  matched.  If  this  be  correctly  done, 
we  term  the  person  incompletely  color-blind.  But  if  blue  and 
violet,  or  one  of  them,  be  selected,  he  is  red- blind  (sees  only  the 
blue  in  the  mixture  of  blue  and  red).  If  he  select  green  or 
gray,  or  one  of  them,  he  is  green-blind. 

In  order  to  corroborate  the  investigation  we  may  employ 
Test  lib.  A  vivid  red  skein  is  given.  The  red-blind  chooses, 
besides  red,  green  and  brown  shades  darker  than  the  red  ; 
while  the  green-blind  chooses  green  and  brown  shades  lighter 
than  the  red.  But  I  believe  myself,  and  I  think  it  is  now  very 
generally  recognized,  that  red-blindness  and  green-blindness 
invariably  go  together.  In  violet  (or  blue)  blindness,  purple, 
red,  and  orange  will  be  confused  in  Test  Ha,  but  this  is  an  ex- 
tremely rare  variety  of  color-blindness.  Total  color-blindness 
will  be  recognized  by  a  confusion  of  all  shades  having  the  same 
intensity  of  light,  and  is  also  rare.  It  is  impossible  by  this  test 
for  any  color  blind  person  to  escape  detection. 

The  individual  tested  should  not  be  allowed  to  name  the 
colors,  but  merely  to  match  them,  as  above  described.  The 
reason  for  this  is  twofold.  First,  because,  although  the  congeni- 
2 


18  DISEASES   OF   THE    EYE. 

tally  color-blind  person  is  usually  unaware  of  his  defect,  yet  ex- 
perience has  taught  him  which  of  his  sensations  are  called  blue, 
red,  etc.,  by  other  people ;  and  hence  he  can  often  apply  the 
right  names  to  colors  which  he  really  does  not  see  as  such.  He 
is  assisted  in  this  by  whatever  of  color-sight  is  left  to  him,  and 
by  the  brightness  and  saturation  of  the  different  colors,  but  is 
liable  to  frequent  mistakes.  Again,  when  the  color-blind  per- 
son does  happen  to  know  of  his  defect,  he  is  often  desirous  of 
concealing  it,  either  because  he  is  ashamed  of  it,  or  from  inter- 
ested motives.* 

A  certain  proportion  of  people  (3.5  per  cent,  of  men  and  less 
than  1  per  cent,  of  w^omen)  are  congenitally  color-blind,  in 
greater  or  less  degree,  without  any  diminution  in  the  other 
visual  functions. 

Acquired  color-blindness  is  found  in  toxic  amblyopia  and  in 
atrophy  of  the  optic  nerve. 

The  Form-Sense  (Acuteness  of  Vision)  is  the  faculty  the  eye 
possesses  of  perceiving  the  shape  or  form  of  objects,  and,  in 
clinical  ophthalmology,  the  testing  of  this  function  is  an  import- 
ant and  ever-recurring  duty. 

In  order  that  an  eye  may  have  good  sight  it  is  necessary  not 
only  that  its  optic  nerve,  retina,  choroid,  and  refracting  media  be 
healthy,  but  also  that  its  refraction  and  accommodation  be  nor- 
mal. When  applied  to  by  a  patient  on  account  of  imperfect 
sight,  it  is  our  first  duty,  as  a  rule,  to  ascertain  accurately  the 
condition  of  refraction  and  accommodation  of  his  eyes.  Should 
these  be  abnormal,  and  it  be  found  that  by  aid  of  the  correcting 
glasses  perfect  vision  is  obtained,  w^e  may  in  general  conclude 
that  the  eye  is  organically  sound,  and  that  the  patient's  com- 
plaints are  due  to  the  defect  in  accommodation  or  refraction. 
If  the  glasses  do  not  restore  perfect  vision,  we  must  then,  by  the 
ophthalmoscope  and  other  methods,  decide  the  nature  of  the 
defect. 


*  More  detailed  information  on  color-blindness  and  Holmgren's  test 
will  be  found  in  Appendix  I, 


THE   SENSE   OF   SIGHT. 


19 


By  Acuteness  of  Vision  (V.)  is  meant  the  power  which  an 
eye,  or  rather  its  macula  lutea,  has  of  distinguishing  form,  any 
anomaly  of  its  refraction,  if  such  exist,  having  been  first  cor- 
rected, i.  e.,  while  the  patient  wears  the  correcting  glasses. 

Now,  in  order  to  measure  the  acuteness  of  vision,  we  must 
have  a  normal  standard  for  comparison,  i.  e.,  we  must  find  what 
is  the  size  of  the  smallest  retinal  image  whose  form  can  be  dis- 
tinguished. We  cannot  measure  this  image  directly  ;  but,  as  its 
size  is  proportional  to  the  visual  angle — the  angle  which  the 
object  subtends  at  the  eye — it  is  sufficient  to  determine  the 
smallest  visual  angle  under  which  the  form  of  an  object  can  be 
distinguished.  It  has  been  found,  experimentally,  that  the 
average  size  of  this  angle  is  5'. 

Fig.  18. 


In  order  practically  to  ascertain  the  acuteness  of  vision,  we 
place  our  patient  with  his  back  to  the  light,  while  facing  him  ; 
at  a  distance  of  6  metres,  and  in  good  light,  are  placed  Snellen's 
Test-types  for  distance.  These  types  are  so  designed  that,  at 
the  distance  at  which  they  should  be  seen,  they  each  subtend  an 
angle  of  5'  at  the  eye.  The  largest  type  should  be  seen  at  60 
metres  (Fig.  18)  by  the  normal  eye,  and  the  types  range  from 
this  down  to  a  size  visible  not  further  off  than  6  metres.  If 
V  =  Acuteness  of  Vision,  d  =  the  distance  from  the  eye  to  be 
tested  to  the  test-types,  and  D  =  the  distance  at  which  the  type 
should  be  distinguishable,  then  V  =  ^-  For  example  :  if  d  =  6 
metres,  a  distance  which  most  rooms  can  command,  and  if  the 
eye  see  type  D  =  6,  then  V  =  f  =  1,  or  normal  V ;  but  if  at  6 


20  DISEASES   OF   THE    EYE. 

metres  the  eye  see  only  D  =  60,  which  should  be  seen  at  60 
metres,  then  V  =  g^,  or  very  imperfect  vision. 

Should  the  patient's  sight  be  so  bad  that  he  is  unable  to  read 
any  of  the  letters,  it  may  be  tested  by  trying  at  what  distance 
he  can  count  the  surgeon's  fingers ;  and  if  he  cannot  even  do 
that,  then  his  power  of  perception  of  light,  his  "  P.L.,"  should 
be  tested.  This  is  done  by  means  of  a  lamp  in  a  dark  room,  the 
eye  being  alternately  covered  and  uncovered,  and  the  patient 
being  required  to  say  when  it  is  "  light,"  and  when  ^'  dark."  If 
the  flame  be  gradually  lowered,  the  smallest  degree  of  illumina- 
tion perceptible  will  be  ascertained. 

The  eyes  must  be  examined  separately,  that  one  not  under 
examination  being  excluded  from  vision  by  being  shaded  with 
the  patient's  own  hand,  or  other  suitable  screen  ;  but  it  must  not 
be  at  all  pressed  on,  as  any  pressure  would  dim  its  vision  when 
its  turn  for  examination  may  come. 

In  advanced  age  the  acuteuess  of  vision  is  often  reduced,  owing 
to  certain  senile  changes  in  the  eye. 


THE  FIELD  OF  VISION. 

By  the  Field  of  Vision  ( F.V.)  is  meant  the  space  within 
which,  when  one  eye  is  closed,  objects  can  be  seen  by  its  fellow, 
the  gaze  of  the  latter  being  fixed  the  while  on  some  one  object 
or  point.  Thus  if,  standing  on  a  hill,  we  fix  the  gaze  of  one  eye 
on  some  object  on  the  plain  below,  the  field  of  vision  includes 
not  only  that  object,  but  many  others  also  for  miles  around  it. 
If  the  fixation  object  be  nearer  to  us,  our  field  of  vision  will  be 
proportionately  diminished  in  extent. 

The  fixation  object  is  seen  by  central  or  direct  vision,  its 
image  being  formed  on  the  macula  lutea;  the  other  objects  in 
the  field  of  vision  correspond  with  as  many  different  points  in 
the  more  peripheral  parts  of  the  retina,  and  are  seen  by  eccen- 
tric, or  indirect,  vision.  Eccentric  vision  is  of  great  importance 
for  the  guiding  of  ourselves  and  avoiding  obstacles  in  our  way. 
Its  use  may  be  realized  by  the  experiment  of  looking  through  a 


THE   FIELD   OF   VISION.  21 

long  small-bore  cylinder  {e.  g.j  a  roll  of  music)  with  one  eye, 
thus  cutting  off  its  eccentric  field,  while  the  other  eye  is  closed. 
The  Dimensions  of  the  Field  of  Vision  may  be  measured  by 
means  of  an  instrument  called  the  perimeter.  This  is  a  semi- 
circular metal  band,  which  revolves  upon  its  middle  point,  being 

Fig.   19. 


Chart  of  F.  V.  of  Right  Eye. 

in  this  way  capable  of  describing  a  hemisphere  in  space.  The 
arc  is  divided  into  degrees  marked  on  it,  from  0°  placed  at  its 
middle  point,  to  90°  at  either  extremity.  At  the  centre  of  the 
hemisphere  is  situated  the  eye  under  examination,  while  the 
fixation  point  is  placed  exactly  opposite,  in  the  centre  of  the 


22 


DISEASES   OF  THE    EYE. 


semicircle.  A  small  square  bit  of  white  paper,  the  test  object, 
is  slowly  moved  along  the  inner  surface  of  the  arc  from  the 
periphery  toward  the  centre,  until  it  comes  into  view.  The 
horizontal,  vertical,  and  two  intermediate  meridians,  at  the 
least,  should  be  examined  by  placing  the  arc  of  the  perimeter  in 
the  corresponding  planes.  The  boundary  of  the  field  may  be 
noted  on  a  diagram  or  chart  (Fig.  19),  which  represents  the 
projection  of  a  sphere  on  a  plane  surface. 


Fig.  20. 


The  radii  represent  different  meridians,  which  may  be  deter- 
mined by  a  dial  with  pointer  on  the  back  of  the  perimeter,  while 
the  concentric  circles  correspond  with  the  degrees  marked  on  the 
perimeter.  A  pencil  mark  is  placed  on  the  chart  at  the  spot 
corresponding  to  that  on  the  perimeter  at  which  the  test  object 
comes  into  view,  and,  when  the  different  meridians  have  been 
examined,  these  marks  are  united  by  a  continuous  line,  which 
then  represents  the  outer  boundary  of  the  F.V. 

The  normal  F.V.  is  not  circular,  but  extends  outward  about 


THE   FIELD   OF   VISION. 


23 


95°,  upward  about  53°,  inward  about  47°,  and  downward 
about  65°,  as  represented  by  the  strong  curve  in  Fig.  19.  The 
limitation  upward  and  inward  is  chiefly  due  to  the  projection 
of  the  supra-orbital  margin  and  the  bridge  of  the  nose,  but  also 
to  the  fact  that  the  outer  and  lower  parts  of  the  retina  are  less 


Chart  of  F.  V.  of  Left  Eye.     {LandoU.) 


practiced  in  seeing  than  are  the  upper  and  inner  parts,  and  their 
functions  consequently  less  developed.  The  acuteness  of  vision 
diminishes  progressively  toward  the  periphery  of  the  field,  two 
points  of  a  certain  size  close  together  being  distinguishable  from 
each  other  only  a  short  distance  from  the  fixation  point,  while 


24  DISEASES   OP   THE   EYE. 

the  further  toward  the  periphery  the  larger  must  be  the  test 
objects. 

Fig.  20  serves  to  illustrate  the  projection  of  the  field  of  vision 
on  the  semicircle  of  the  perimeter  to  its  extreme  temporal  (95°) 
and  its  extreme  nasal  (47°)  boundaries,  as  well  as  the  portion  of 
the  retina  (a  to  b)  which  corresponds  to  this  extent  of  field,  and  it 
shows  that  the  sensitive  portion  of  the  retina,  or  rather  perhaps 
the  portion  of  the  retina  which  is  most  used,  extends  further 
forward  on  the  nasal  than  on  the  temporal  side.  The  diagram 
also  explains  the  remarkable  fact  that  the  field  extends  in  the 
temporal  direction  more  than  90°. 

The  Blind  Spot  of  Mariotte  is  a  small  blind  island,  or  scotoma, 
situated  about  15°  to  the  outer  side  of  the  point  of  fixation,  and 
just  below  the  horizontal  meridian.  It  is  shown  as  a  white  spot 
in  Fig.  21.  It  is  due  to  the  optic  papilla,  for  at  that  place  the 
outer  layers  of  the  retina  are  wanting,  and  hence  there  is  there 
no  power  of  perception.  There  are  also,  occasionally,  minute 
blind  spots  in  the  field  due  to  the  retinal  vessels,  which  interfere 
with  the  formation  of  the  image  upon  the  layer  of  rods  and  cones. 

The  Perception  of  Colors  in  the  Perijjhery  of  the  Field  can  be 
examined  with  the  perimeter,  by  means  of  bits  of  colored  paper 
4  mm.  square.  It  has  been  in  this  way  ascertained  that  the 
boundaries  of  the  power  of  eccentric  perception  for  the  different 
colors  do  not  seem  to  correspond  with  the  boundary  for  white 
light,  nor  do  the  boundaries  of  the  different  colors  coincide. 
Examining  from  the  periphery  toward  the  centre  by  ordinary 
daylight,  blue  is  the  color  which  can  be  distinguished  as  such 
most  eccentrically,  its  field  extending  nearly  as  far  as  the  general 
F.V. ;  then  come  yellow,  orange,  red,  and,  with  the  most  limited 
field,  green.  Blue,  red,  and  green  being  the  most  important, 
their  fields  are  noted  in  Fig.  21.  Although  the  respective  colors 
are  distinguishable  within  the  limits  indicated,  they  are  by  no 
means  so  brilliant  in  hue  as  when  seen  by  direct  vision.  It  has, 
however,  been  demonstrated  that  every  color  is  recognizable  up 
to  the  outer  limit  of  the  F.V.  if  sufficiently  illuminated  ;  so  that 
there  is,  in  fact,  no  absolute  color-blindness  in  these  parts  of  the 
retina,  but  merely  a  diminished  sensitiveness  to  colored  light. 


CHAPTER  II. 

ABNORMAL  REFRACTION  AND 
ACCOMMODATION. 

I  have  explained  what  is  meant  by  Normal  Refraction,  or 
Emmetropia  (s'a-.ac-oov,  the  standard;  w^,  eye).  We  recognize 
three  different  forms  of  Abnormal  Refraction,  or  Ametropia 
(a,  priv.;  txhpo'j,  standard;  axj.').  1.  Hypermetropia  {o-sp, 
over;  iii-pov,  standard;  w^),  in  which  the  principal  focus  of 
parallel  rays  of  light  lies  behind  the  retina.  2.  Myopia  Qiozi-^, 
to  dose;  (^4'),  or  Short-sight,  in  which  the  principal  focus  of  such 
rays  lies  in  front  of  the  retina.  3.  Astigmatism  (a,  priv, ;  ari-pia, 
a  point),  in  which  the  refraction  of  the  eye  in  its  different  meri- 
dians is  different. 

Hypermetropia. 

In  a  large  proportion  of  cases,  this  form  of  Ametropia  is  due 
to  the  eyeball  being  too  short  in  its  antero-posterior  axis  (Axial 
H).  It  may  also  depend  upon  deficient  refracting  power  in  the 
dioptric  media  (Curvature  H). 

Fig.  22. 


Parallel  rays  of  light  falling  into  the  hypermetropic  eye  {E, 
Fig.   22)  do  not  meet   on  the  retina,  but  converge  toward  a 
3  25 


26  DISEASES   OF   THE    EYE. 

point  (c)  situated  behind  it.  Consequently,  these  rays  do  not 
form  on  the  retina  a  distinct  image  of  the  object  looked  at,  but 
produce  there  a  "  circle  of  diffusion  "  (d  e),  or  blurred  represen- 
tation of  the  object. 

Since,  therefore,  in  hypermetropia  the  retina  is  in  front  of  the 
principal  focus  of  the  dioptric  system,  rays  passing  out  of  the 

Fig.  23. 


eye  from  any  point  (i?.  Fig.  23)  on  this  retina  will  pass  out  as 
divergent  rays,  and  will  appear  to  come  from  a  point  (i?')  situ- 
ated behind  the  eye,  which  point  is  the  virtual  conjugate  focus 
of  the  point  R  (compare  Fig.  5). 

Now,  in  order  to  correct  the  hypermetropia — that  is,  to  render 


Fig.  24. 


the  eye  emmetropic,  so  that  parallel  rays  passing  into  it  may  be 
brought  to  a  focus  on  the  retina — a  convex  lens  (X,  Fig.  24) 
must  be  placed  in  front  of  the  eye,  of  sufficient  strength  to  render 
the  parallel  rays,  before  they  enter  the  eye,  convergent  toward 
R\  so  that  when   they  meet  the  eye  they  may  be  brought  to  a 


HYPERMETROPIA.  27 

focus  on  the  retina  R,  which  is  the  conjugate  focus  of  R'.  The 
higher  the  hypermetropia,  i.e.,  the  shorter  the  antero-posterior 
axis  of  the  eyeball,  the  stronger  must  the  correcting  glass  be. 
It  may  be  found  that,  with  a  lens  of  some  dioptrics  less  power, 
the  eye  will  see  equally  well ;  but  this  it  does  by  means  of  an  effort 
of  accommodation  which  supplements  the  inadequate  refracting 
power  of  the  lens  placed  before  it.  As  we  proceed  to  higher 
lenses,  the  effort  of  accommodation  is  relaxed,  until,  finally,  the 
strongest  lens  with  which  vision  is  still  at  its  best  is  reached, 
when,  it  may  for  the  present  be  assumed,  no  further  effort  of 
accommodation  is  made,  and  L  represents  the  whole  error  of  re- 
fraction. In  low  degrees  of  hypermetropia  the  eye  can  frequently 
see  distant  objects  distinctly  by  an  effort  of  accommodation, 
which  completely  takes  the  place  of  L.  When  such  an  eye  is 
found  to  have  full  vision  without  a  glass,  a  beginner  might  fall 
into  the  error  of  regarding  it  as  emmetropic ;  but  if  he  take  the 
precaution  of  placing  a  low  convex  lens  in  front  of  it,  and  then 
find  that  the  acuteness  of  vision — the  effort  of  accommodation 
being  now  relaxed — remains  as  good  as  without  the  glass,  he 
will  avoid  the  mistake. 

If  a  glass  a  single  number  higher  than  the  exact  measure  of 
the  defect  be  placed  before  the  eye,  vision  again  becomes  indis- 
tinct, because  the  rays  are  then  brought  to  a  focus  in  front  of 
the  retina,  and  a  circle  of  diffusion  is  formed  on  the  latter. 
The  eye,  in  fact,  is  put  by  such  a  glass  in  a  condition  of  myopia. 
Therefore,  the  stronger  convex  glass  ivith  ivhich  a  hypermetropic 
eye  can  see  distajit  objects  (the  test-types)  most  distinctly  is  the  glass 
which  corrects  its  hypermetropia,  and  is  the  measure  of  the  latter. 
Very  commonly  it  is  only  the  manifest  hypermetropia  (vide 
infra)  which  is  ascertained  by  this  method,  unless  the  accommo- 
dation has  been  previously  paralyzed  by  atropine. 

This  method  of  determining  the  refraction  by  means  of  the 
trial-lenses  and  test-types  is  not  relied  on  nowadays  by  ophthal- 
mic surgeons  to  the  same  extent  as  formerly,  the  examination  of 
the  upright  ophthalmoscopic  image,  or  else  retinoscopy,  having 


28  DISEASES   OF   THE    EYE. 

largely  taken  its  place.     In  conjunction  with  these  it  is  a  valu- 
able method. 

The  degree  of  the  hypermetropia  is  indicated,  as  has  been 
said,  by  the  number  of  the  lens  which  corrects  it.  Thus,  if  the 
number  of  the  glass,  L  (Fig.  24),  required  to  correct  the  hyper- 
metropia of  the  eye,  E,  be  2.0  D,  we  say  this  eye  is  hyperme- 
tropic two  dioptrics,  or  has  a  hypermetropia  of  two  dioptrics 
(H  =  2.0  D). 

Amplitude  of  Accominodatioii  in  Hypermetropia. — When  at 

rest  the  refraction  of  the  hypermetropic  eye  is  deficient  ;  consequently 
r  must  be  negative  (  —  r),  and  the  amplitude  of  accommodation  must 
include  the  power  required  to  adapt  the  eye  to  infinity  ;  therefore — 
a  ^=  p  —  (  —  r)  ^=p  -\-  r. 
For  example  :  if  the  punctum  proximum  of  a  hypermetropic  eye  of 
5  D  be  at  30  cm.,  what  is  the  amplitude  of  accommodation?  5  D 
(=  r)  is  necessary  in  order  to  make  the  eye  emmetropic,  and  to  accom- 
modate the  emmetropic  eye  to  30  cm.  3.25  D  (Vr-  ~  3-25)  is  required. 
Hence  a  =  3.25  +  5  =  8.25  D. 

The  Angle  y  in  Hypermetropia. — In  hypermetropia,  as  in  emme- 
tropia,  the  cornea  is  cut  to  the  inside  of  its  axis  by  the  visual  line ;  but  in 

hypermetropia  the  angle 
Fig.    25.  which    the    visual    line 

forms  with  the  axis  of 
the  cornea  is  very  much 
greater,  owing  to  the 
shortness  of  the  eyeball, 
and  the  efi'ect  is  to  in- 
crease the  distance  be- 
tween the  macula  lutea 
(M)  and  the  optic  axis 
(A)  (Fig.  25).  Conse- 
quently, in  extreme  cases,  when  the  visual  lines  of  a  hypermetropic 
individual  are  directed  to  an  object,  the  axes  of  the  cornea3  may  seem  to 
diverge,  and  thus  the  appearance  of  a  divergent  strabismus  will  be 
given. 

The  evil  effects  of  the  constant  and  excessive  demand  upon 
the  accommodation  in  hypermetropia  are  chiefly  these  : — 
1.  Cramp  of  the  Ciliary  Muscle. — Its  persistently  maintained 


HYPERMETROPIA.  29 

contraction  frequently  gives  rise  to  a  tonic  cramp  of  the  muscle. 
This  spasm  is  not,  or  may  be  only  partially,  relaxed  when  the 
correcting  convex  glass  is  held  before  the  eye;  and,  conse- 
quently, the  whole  or  part  of  the  hypermetropia  may  be  masked 
by  the  cramp.  That  part  of  the  hypermetropia  which  is  thus 
masked  is  called  latent  (HI),  while  the  part  which  is  revealed  by 
the  convex  glass  is  called  manifest  (Hm).  The  entire  hypermetro- 
pia is  made  up  of  the  latent  and  manifest  H  (H  =  Hm  -\-  HI). 

If  the  cramp  be  excessive,  parallel  rays  may  be  kept  conver- 
gent on  the  retina  by  it  alone,  and  vision  then  would  be  made 
worse,  rather  than  better,  by  even  a  weak  convex  glass  held  be- 
fore the  eye,  a  circumstance  which  might  lead  the  surgeon  to 
think  he  had  to  do  with  an  emmetropic  eye.  In  this  case  we  say 
that  the  whole  hypermetropia  is  latent. 

Or,  in  extreme  cases  of  accommodative  spasm,  parallel  rays 
may  be  united  in  front  of  the  retina,  and  the  eye  made  appar- 
ently myopic,  the  vision  being  capable  of  improvement  by  con- 
cave glasses.  Serious  errors  might  therefore  arise  if  this  cramp 
were  overlooked,  as  it  is  very  apt  to  be  in  the  examination  with 
the  trial-lenses.  When  it  is  present  in  a  high  degree,  the 
patient  cannot  maintain  a  sustained  view  of  an  object  at  any 
distance  without  suffering  pain  in  and  about  the  eyes.  It  is 
frequently  the  reason  why  perfect  acuteness  of  vision  is  not 
obtained  by  aid  of  the  trial-lenses,  and  the  surgeon  must  be 
careful  not  to  be  led  into  an  error  of  diagnosis  by  it.  Exami- 
nation with  the  ophthalmoscope,  or  paralysis  of  accommodation 
with  atropine,  will  enable  him  to  avoid  mistakes. 

In  order  to  relieve  this  cramp,  the  ciliary  muscle  must  be 
paralyzed  by  a  solution  of  atropine  freely  instilled ;  and  it  will 
often  be  necessary  to  keep  the  accommodation  paralyzed  for 
some  days,  and  to  commence  the  use  of  the  correcting  spectacles 
before  the  effect  of  the  atropine  begins  to  wear  off.  In  this  way 
a  recurrence  of  the  spasm  may  be  often  prevented. 

As  life  advances,  and  the  power  of  accommodation  diminishes, 
the  manifest  part  of  the  hypermetropia  increases,  while  the 
latent  part  decreases,  until  finally  Hm  =  H. 


30  DISEASES   OF   THE    EYE. 

2.  Accommodative  Asthenopia. — In  looking  at  distant  objects 
the  accommodation  of  the  normal  eye  is  at  perfect  rest,  and  does 
not  come  into  play  until  the  object  is  approached  close  (within 
6  m.)  to  the  eye.  But  even  for  distant  objects  the  hypermetropic 
eye  must  accommodate ;  and,  having  for  those  distances  used  up 
part  of  its  accommodative  energy,  it  has  for  near  objects  actually 
less  at  disposition  than  the  normal  eye.  Hence  we  find  that 
hypermetropic  people  often  complain  of  inability  to  sustain  ac- 
commodative efforts  for  near  objects  for  any  length  of  time. 
After  reading,  sewing,  etc.,  for  a  short  time,  sensations  of 
pressure  in  the  eyes  and  of  weight  above  and  around  them  come 
on,  and  the  words  or  stitches  become  indistinct,  and  cannot  be 
distinguished.  The  work  must  then  be  interrupted,  and  after  a 
few  minutes'  rest  can  be  resumed,  but  must  soon  again  be  given 
up.  After  a  Sunday's  rest  the  patient  is  often  able  to  get  on 
better  than  on  the  previous  Saturday.  These  symptoms  depend 
simply  upon  inability  of  the  ciliary  muscle  to  perform  the  ex- 
cessive demands  made  upon  it. 

Accommodative  Asthenopia  {a,priv.;  aOhoq^  strength;  w^'O?  as 
this  group  of  symptoms  is  called,  often  appears  suddenly  during 
or  after  illness.  The  explanation  of  this  is  that  although  hyper- 
metropia  had  always  existed,  yet  in  health  the  ciliary  muscle 
was  equal  to  the  great  efforts  required  of  it,  but  in  sickness  it 
shared  the  debility  of  the  system  in  general.  To  relieve  accom- 
modative asthenopia,  we  have  merely  to  prescribe  those  lenses 
for  near  work  which  correct  the  hypermetropia,  and  by  this 
means  to  place  the  eyes  in  the  position  of  emmetropic  eyes. 

3.  Internal,  or  Convergent,  Concomitant  Strabismus. — This 
condition  has  a  certain  relation  to  hypermetropia.  It  will  be 
treated  of  in  the  chapter  on  the  Motions  of  the  Eyeballs  and 
their  Derangements  (Chap.  XXI). 

The  Prescribing  of  Spectacles  in  Hypermetropia. — If  a  per- 
son be  found  to  be  hypermetropic,  but  his  acuteness  of  vision 
without  glasses  be  good,  or  as  good  as  he  desires,  and  he  com- 
plain of  no  asthenopic  symptoms,  glasses  need  not,  indeed  should 
not,  be  prescribed  for  him.     No  disease  in  his  eye  will  result 


MYOPIA.  31 

from  his  going  without  glasses.     At  the  most  he  may  get  cramp 
of  accommodation. 

If  the  patient  complain  of  imperfect  distant  vision  due  to 
hypermetropia,  then  those  lenses  which  correct  the  Hm  may  be 
prescribed  for  distant  vision,  to  be  worn  either  constantly  or 
occasionally,  as  he  may  desire.  Such  a  patient  is  almost  certain 
to  complain  also  of  accommodative  asthenopia;  while  many 
patients  will  be  met  with  who  complain  of  the  latter,  yet  express 
themselves  as  perfectly  satisfied  with  their  distant  vision.  For 
relief  of  the  asthenopia  it  is  usually  enough  to  prescribe  spectacles 
for  near  work  which  will  correct  the  Hm,  along  with  1  D  or  2  D 
of  the  HI,  if  the  latter  exist. 

Fig.  26. 


If  there  be  excessive  cramp  of  accommodation,  glasses  to  cor- 
rect the  whole  hypermetropia  should  be  worn  while  the  eye  is 
under  atropine ;  and  afterward  as  much  of  the  HI  as  possible, 
along  with  the  Hm,  should  be  corrected  by  glasses  to  be  worn 
constantly. 

Myopia,  or  Short-sight. 

This  form  of  ametropia  is  due,  in  a  vast  majority  of  cases,  to 
the  an tero- posterior  axis  of  the  eyeball  being  too  long  (Axial 
M.),  and  hence,  its  refracting  media  not  being  proportionately 
diminished  in  power,  parallel  rays  of  light  (a  h,  Fig.  26)  are  not 
brought  to  a  focus  on  the  retina,  but  in  front  of  it  (at/),  and 
form  on  the  retina  circles  of  diffusion  (c  d). 

Myopia  may  also  be  caused  by  abnormally  high  refracting 


32  DISEASES   OF   THE   EYE. 

power  ill  the  crystalline  lens,  as  in  spasm  of  the  ciliary  muscle, 
and  in  some  cases  of  commencing  cataract,  and  also  by  conical 
cornea.     (Curvature  M.) 

Since,  in  the  myopic  eye,  the  retina  is  beyond  the  principal 
focus  of  the  dioptric  system,  rays  emerging  from  any  point  (c. 
Fig.  27)  of  the  fundus  will  pass  out  convergently,  and  will  unite 
in  front  of  the  eye  at  the  conjugate  focus  of  the  retina  (r). 
(Compare  Fig.  4.) 

Conversely,  rays  diverging  from  a  certain  point  (r)  in  front  of 
the  eye  will  be  focused  on  the  retina  (c). 

If  an    object  be  brought  toward  the  eye,  the  divergence  of 

Fig.  27. 


those  rays  which  pass  from  it  into  the  eye  increases,  until,  when 
it  has  reached  the  point  r,  their  divergence  is  just  sufficient  to 
allow  them  to  be  united  at  the  conjugate  focus  c,  which  is  on  the 
retina.  This  point  r  is  the  punctum  remotum-^^  of  the  myopic 
eye.  In  order,  therefore,  that  the  short-sighted  eye  may  be  able 
to   see   distant   objects,  it  is  necessary  that  the   parallel  rays 

*  The  punctum  remotum  is  always  the  conjugate  focus  of  the  retina. 
In  an  emmetropic  eye  it  is  at  infinity,  since  the  retina  is  at  the  principal 
focus  of  the  eye,  and  the  rays  pass  out  parallel.  In  hypermetropia  it  is 
behind  the  eye,  and  is  virtual  or  negative,  because  the  retina  is  in  front 
of  the  principal  focus,  and  the  rays  pass  out  divergently,  as  if  coming 
from  a  point  behind  the  retina.  Lastly,  in  myopia  it  is  situated  at  a  finite 
distance  in  front  of  the  eye,  and  is  real  and  positive,  because  the  retina 
is  beyond  the  principal  focus,  and  the  rays  emerge  convergently. 


MYOPIA.  33 

coming  from  those  objects  should  be  given  such  a  degree  of  diver- 
gence before  they  pass  into  the  eye  as  though  they  came  from 
this  punctum  remotum.  This  can  readily  be  effected  by  placing 
the  suitable  concave  lens  in  front  of  the  eye,  and  the  number  of 
this  glass  will  indicate  the  degree  of  the  myopia,  i.e.,  by  how 
many  dioptrics  the  refracting  power  of  the  eye  is  in  excess  of 
that  of  an  emmetropic  eye.  The  focal  length  of  the  correcting 
glass  corresponds,  of  course,  with  the  distance  of  the  punctum 
remotum  from  the  eye,  provided  the  glass  be  held  close  to  the 
cornea.  The  focus  of  the  glass  and  the  punctum  remotum  of 
the  eye  are  then  identical,  and,  therefore,  parallel  rays,  after 
passing  through  the  glass,  will  have  a  divergence  as  though  they 

Fig.  28. 


came  from  this  point,  and  will  form  an  exact  image  of  the  object 
from  which  they  come  on  the  retina. 

For  example  :  if  the  punctum  remotum  (Fig.  28)  be  situated 
at  14  cm.  from  the  eye,  then  the  number  of  the  correcting  lens 
will  be  7  D,  because  the  focal  distance  of  this  lens  is  14  cm. 
('T'T  =  '^)-  ^^  practice,  however,  we  cannot  hold  the  glass  so 
close  to  the  cornea,  and,  therefore,  we  must  subtract  the  distance 
between  it  and  the  cornea  from  the  focal  distance  of  the  required 
lens.  In  the  above  case,  suppose  the  distance  from  cornea  to 
glass  be  4  cm.,  the  required  lens  will  be  10  D  (-\2^  =  10). 

Determination  of  the  Degree  of  Myopia. — The  degree,  or 
amount,  of  myopia,  as  of  hypermetropia,  may  be  determined 
either  by  the  ophthalmoscope,  or  experimentally,  by  means  of 
the  trial-lenses  and  test-types. 


34  DISEASES   OF   THE   EYE. 

By  the  latter  method,  examining  each  eye  separately,  we  find 
the  correcting  glass  by  placing  our  patient  as  directed  in  the 
section  on  Acuteness  of  Vision.  A  weak  concave  trial-glass  is 
then  held  before  the  eye  under  examination,  and  higher  numbers 
are  gradually  proceeded  to,  until  the  glass  is  reached  which  gives 
the  eye  the  best  distinguishing  power  for  the  types.  We  often 
find  that  there  are  several  glasses,  with  each  of  which  the  patient 
can  see  equally  well.  The  weakest  of  these  is  the  measure  of  his 
myopia.  When  a  higher  class  is  used  the  eye  may  still  see  well, 
but  it  does  so  only  by  an  effort  of  accommodation,  and  the  glass 
employed  represents  not  merely  the  myopia  present,  but  also  this 
accommodative  effort.     No  more  serious  mistake  can  be  made 

Fig.  29. 


than  the  prescribing  of  too  strong  concave  glasses  for  a  myopic 
individual,  as  will  be  seen  further  on. 

The  Amplitude  of  Accommodation  in  Myopia. — The  myopic  eye 
has  an  excess  of  refractive  power  as  compared  with  the  emmetropic  eye  ; 
therefore,  in  calculating  its  amplitude  of  accommodation,  this  excess 
must  be  subtracted  from  the  positive  refractive  power  ( p)  which  would 
be  required  to  adapt  the  emmetropic  eye  to  the  same  punctum  proximum  ; 
or,  in  other  words,  the  myopic  eye  has  need  of  less  accommodative  power 
than  the  emmetropic  eye,  because,  even  at  rest,  it  is  adapted  for  a  dis- 
tance (R.,  its  punctum  remotum)  for  which  the  emmetropic  eye  has  to 
accommodate  ;  hence,  in  myopia — 

a  =  p  —  r. 
For  example,  a  myopic  person  of  10  D  who  can  accommodate  up  to  8  cm. 
{p  =  W  =  12  D)  has  an  amplitude  of  accommodation  of  12  —  10  =  2  D. 

The  Angle  y  in  Myopia. — In  myopia,  owing  to  the  length  of  the 


jvnropiA.  35 

eyeball,  the  cornea  is  cut  much  closer  to  its  centre  by  the  visual  line 
than  in  emmetropia  ;  or,  these  two  lines  may  coincide  ;  or,  the  cornea 
may  even  be  cut  to  the  inside  of  its  centre  by  the  visual  line  {vide  Fig. 
29).  In  any  of  these  cases,  but  especially  in  the  latter,  the  effect  will  be 
that  of  an  apparent  convergent  strabismus. 

Myopia  is  rarely,  or  never,  congenital.  It  generally  first 
shows  itself  from  the  eighth  to  the  tenth  year,  and  is  apt  to 
increase,  especially  during  the  early  years  of  puberty.  Its 
progressive  increase  is  encouraged  by  use  of  the  eye  for  near 
work,  such  as  reading,  sewing,  drawing,  etc.,  and  is  due  to  a 
further  elongation  of  the  antero-posterior  optic  axis.  But  it  is 
certain  that,  in  addition  to  this  exciting  cause,  there  must  be 
some  predisposing  condition,  or  conditions,  as  only  a  few 
children  become  short-sighted,  although  they  are  all  educated 
in  a  very  similar  manner,  so  far  as  the  use  of  their  eyes  is 
concerned.  Stilling"^  and  Seggel  f  have  found  that  a  low  orbit 
is  usually  associated  with  a  myopic  formation  of  eyeball,  and 
they  are  inclined  to  regard  these  largely  in  the  light  of  cause 
and  effect.  For  with  a  low  orbit,  and  when,  as  often  happens, 
the  tendon  of  the  superior  oblique  has  an  almost  transverse 
direction,  the  combined  pressure  of  the  two  obliques  upon  the 
plane  of  the  equator  during  the  period  of  growth  would  tend 
to  cause  elongation  of  the  anterior-posterior  diameter  of  the 
eyeball.  Certain  it  is  that  myopia  is  often  hereditary  and 
seen  in  several  members  of  a  family.  The  whole  question  of 
the  predisposing  causes  of  myopia  must  still  be  regarded  as 
subjudice. 

In  cases  of  commencing  cataract  a  slight  degree  of  myopia 
may  sometimes  be  noticed  to  come  on.  This  is  due  to  a  higher 
refracting  power  in  the  lens  as  the  result  of  the  changes  begin- 
ning in  it. 

HirschbergJ  states  that  late  myopia  coming  on  without  cata- 

*  Trans.  Interhat.  Ophth.  Congress,  1888,  p.  97. 

t  Von  Grcefe^s  Archie,  xxxvi,  II,  p.  1. 

X  Deutsche  Med.  Wochenschr.,  1891,  No.  13. 


36  DISEASES    OF    THE    EYE. 

ract  from  the  fortieth  to  the  sixtieth  year  is  a  very  certain 
sign  of  diabetes.  He  offers  no  explanation  of  its  occurrence  in 
this  way.     I  have  not  myself  seen  such  a  case. 

Many  short-sighted  people  half  close  their  eyes  when  endea- 
voring to  distinguish  distant  objects,  in  order  that  the  rays 
may  be  prevented,  so  far  as  possible,  from  passing  through 
peripheral  parts  of  the  crystalline  lens,  which  would  increase 
the  circles  of  diffusion.  This  habit  it  is  which  has  given  the 
name  of  myopia  to  the  condition. 

Progressive  Myopia  frequently  becomes  complicated  with 
Organic  Disease,  viz: — 1.  Posterior  Staphyloma. — This  condition 
is  recognized  by  the  ophthalmoscope  as  a  white  crescent  at  the 
outer  side  of  the  optic  papilla.  Owing  to  bulging  of  the  eye- 
ball, the  choroid  becomes  atrophied  at  this  place,  and  admits 
of  the  white  sclerotic  being  seen.  The  staphyloma  sometimes 
extends  all  round  the  optic  papilla  ;  and,  by  stretching  of  the 
retina  in  these  extreme  cases,  its  functions  may  become  de- 
ranged, and,  in  consequence,  the  blind  spot  increased  in  size. 

2.  Choroidal  Degeneration  in  the  Xeicjhhorhood  of  the  Macula 
Lutea. — This  should  always  be  carefully  looked  for,  as  the  region 
of  the  yellow  spot  is  very  liable  to  disease  in  bad  cases  of  pro- 
gressive myopia.  The  disease  seems  to  begin  in  the  choroid, 
giving  the  appearance  of  small  cracks  or  fissures,  which  later  on 
develop  into  a  patch  of  choroidal  atrophy.  The  retina  at  the 
spot  becomes  disorganized,  and  very  serious  disturbance  of 
vision  is  the  result,  the  patient  being  disabled  from  reading. 

3.  Hemorrhage  in  the  Retina  at  the  Yelloiv  Spot  may  occur, 
causing  similar  visual  defects  ;  and,  when  the  hemorrhage  becomes 
absorbed,  the  macula  lutea  may  not  recover  its  function,  owing 
to  the  delicate  retinal  tissue  having  been  seriously  damaged. 
Yet  we  often  meet  with  cases  of  this  kind  which  do  regain  their 
former  vision. 

4.  Detachment  of  the  Retina. — This  is  a  frequent  and  most 
serious  complication  of  progressive  myopia.  It  will  be  fully 
considered  in  the  chapter  on  Diseases  of  the  Retina  (Chap. 
XV). 


MYOPIA.  37 

5.  Opacities  in  the  Vitreous  Humor. — These  often  accompany 
the  choroidal  alterations. 

Insufficiency  of  the  Internal  Recti  Muscles  is  another  anomaly 
which  we  find  very  commonly  associated  with  progressive 
myopia ;  but  it  can  hardly  be  regarded  as  an  organic  disease,  or 
as  a  result  of  progressive  myopia.  It  may  more  properly  be 
looked  upon  as  a  concomitant  congenital  irregularity,  and,  per- 
haps, as  one  of  the  causes  of  the  progressive  nature  of  myopia. 
It  will  be  fully  discussed  in  Chapter  XVIII. 

Cramp  of  Accommodation  is  often  present  in  myopic  eyes,  and 
will  cause  the  myopia,  examined  with  trial-lenses  and  test-types, 
to  seem  higher  than  it  is.  The  surgeon,  being  aware  of  this 
source  of  error,  will  guard  against  it. 

The  Management  of  Myopia. — The  great  danger  of  myopia 
being  its  progressive  increase,  with  consequent  or  attendant 
organic  disease,  its  management  is  one  of  our  most  important 
and  difficult  tasks,  especially  in  these  days  of  high-pressure 
education.  Many  cases  of  myopia  are  not  progressive,  and 
cause  no  anxiety ;  others  are  periodically  progressive  ;  and  again, 
others  are  continuously  or  absolutely  progressive.  In  the  periodi- 
cally progressive  form  the  age  of  puberty  is  usually  the  time  of 
greatest  increase  and  greatest  danger,  the  myopia  often  becoming 
stationary  later  on.  In  the  absolutely  progressive  cases  the 
increase  goes  on  rapidly  until  after  puberty,  and  then  more 
slowly,  but  it  usually  leads  to  considerable  loss  of  vision  unless 
the  greatest  care  be  taken. 

In  the  progressive  forms,  close  approximation  of  the  eyes  to 
the  work,  meaning  convergence  of  the  visual  lines  and  accom- 
modative effort,  as,  also,  everything  which  tends  to  cause  conges- 
tion of  the  eyes  and  head,  are  what  we  have  to  try  to  prevent. 
In  order  that  these  patients  may  not  be  obliged  to  approach 
close  to  their  work,  they  should  occupy  themselves  with  large, 
and  not  with  minute  objects,  and  only  by  good  light.  When 
possible  (vide  infra)  such  spectacles  should  be  prescribed  for 
them  as  will  enable  them  to  read  at  a  distance  of  25  to  30  cm. 
In  reading  and  writing,  the  books  and  papers  should  be  on  a 


38  DISEASES   OF   THE    EYE. 

slope,  to  facilitate  an  upright  position  of  the  head,  and  the  table 
should  not  be  too  low.  They  should  pause  to  rest  for  some 
minutes  occasionally  during  the  spell  of  work,  while  the  number 
of  working  hours  in  the  day  should  be  restricted.  The  action 
of  the  bowels  should  be  regulated,  the  feet  kept  warm,  and  all 
excessive  bodily  exertion  avoided,  so  that  congestion  of  the  head 
and  eyes  may  be  prevented.  Where  posterior  staphyloma, 
hemorrhages  at  the  macula  lutea,  or  opacities  in  the  vitreous 
humor  are  present,  Heurteloup's  artifical  leech  applied  to  the 
temple,  mild  purgatives,  and  complete  rest  of  the  eyes,  with  the 
use  of  atropine  for  some  weeks  to  immobilize  the  ciliary  muscle, 
are  to  be  ordered.  If  the  choroidal  changes  be  very  marked, 
small  doses  of  the  perchloride  of  mercury  are  indicated.  The 
eyes  should  be  protected  from  light  by  blue  or  smoked  protection- 
spectacles,  this  latter  precaution  being  especially  necessary  during 
the  use  of  atropine.  Insufficiency  of  the  internal  recti  should 
be  corrected  by  prisms,  or  by  operation. 

The  correction  of  the  myopia  by  suitable  glasses  is  an  impor- 
tant and  difficult  matter.  In  some  cases  of  slight  myopia  (2.5 
T>  and  less),  in  young  patients  with  good  amplitude  of  accommo- 
dation, the  correcting  glasses  may  be  prescribed  to  be  worn 
constantly  for  near  as  well  as  for  distant  objects,  and  thus  the 
patient  is  placed  in  the  position  of  an  emmetrope.  In  other 
cases,  where  the  error  of  refraction  is  not  excessive,  and  the  eye 
is  organically  healthy,  the  whole  defect  may  be  corrected  for 
distant  vision,  if  the  individual  be  warned  not  to  use  his  glasses 
for  near  work,  lest  he  should  strain  his  accommodation.  In  high 
degrees  of  myopia  strong  glasses  may  be  given  for  distant  vision, 
but  it  is  wise  to  give  them  1  D  or  1.5  D  less  than  the  full  cor- 
rection, so  that  all  danger  of  accommodative  effi)rt  may  be 
avoided.  In  these  same  cases,  provided  there  be  no  ophthalmo- 
scopic changes,  or  only  some  of  minor  significance,  and  if  the 
vision  be  good,  such  a  glass  may  be  given  as  will  enable  the 
patient  to  read  at  25  to  30  cm.  This  glass  may  be  found  by 
subtracting  from  the  number  of  the  glass  representing  the  degree 
of  the  myopia    (say  7  D)  the  lens   whose  focal  length  corres- 


ASTIGMATISM.  39 

ponds  to  the  distance  (say  30  cm.)  required  (this  here  would 
be  3.25  D,  because  Vf"  =  3.25,  and  then  7.0  —  3.25  =  3.75  D,  the 
glass  required).  By  aid  of  such  glasses  this  myope  can  read  at  a 
distance  much  more  favorable  for  the  convergence  of  his  optic 
axes,  and  for  the  erect  position  of  his  head  ;  but  there  is  a 
danger  associated  with  their  use — namely,  that  if  the  patient 
aproach  his  book  closer  than  the  prescribed  distance,  he  does 
away  w^ith  the  advantage  he  should  gain  from  them,  and,  by 
necessitating  an  effort  of  accommodation,  turns  them  to  a  serious 
souirce  of  danger  for  the  eye.  Patients  in  whom  the  acuteness  of 
vision  is  much  lowered  are  liable  to  approach  their  work  in  this 
way,  in  order  to  obtain  larger  retinal  images,  the  more  so  as  the 
concave  glasses  diminish  the  size  of  the  images,  and  in  such 
cases  it  is  better  not  to  give  glasses  for  near  work.  It  is  often 
necessary  to  provide  patients  with  spectacles  which  will  enable 
them  to  use  their  eyes  for  some  special  purpose  at  a  given  dis- 
tance, e.g.^  the  pianoforte,  painting,  etc.,  and  these  can  be  found 
as  above  explained. 

Astigmatism. 

This  is  a  compound  form  of  ametropia,  due  to  the  cornea 
being  more  curved  in  one  meridian  than  in  another,  similarly 
as  the  back  of  the  bowl  of  a  spoon  is  more  convex  from  side  to 
side  than  from  heel  to  point. 

In  Regular  Astigmatism  the  directions  of  the  greatest  and 
least  curvations  of  the  cornea  are  always  at  right  angles  to  each 
other,  and  usually  fall  precisely  in  the  vertical  and  horizontal 
meridians,  the  meridian  of  greatest  curvature  being  most  fre- 
quently the  vertical.  Consequently,  we  say  the  astigmatism  is 
"  with  the  rule  "  in  those  cases  in  which  the  meridian  of  greatest 
curvature  is  the  vertical  ;  and,  where  that  meridian  is  the  one 
of  least  curvature,  we  say  the  astigmatism  is  "  against  the  rule." 
The  result  of  this  is,  that  a  pencil  of  rays  passing  into  the  eye, 
instead  of  meeting  at  a  common  focus,  is  irregularly  refracted, 
those  rays  passing  through  the  vertical  meridian  of  the  cornea 
being  brought  to  a  focus  much  earlier  than  those  which  fall 


40  DISEASES   OF   THE   EYE. 

through  its  horizontal  meridian  ;  and,  therefore,  at  the  focus  of 
the  former  the  latter  rays  form  a  horizontal  streak  of  light. 
The  intermediate,  or  oblique,  meridians  will  probably  be  of 
regularly  intermediate  refracting  power. 

The  interval  between  the  foci  of  the  two  principal  meridians 
is  called  the  Focal  Interval,  and  is  a  measure  of  the  astig- 
matism. 

The  accompanying  diagram  (Fig.  30),  after  Bonders,  will 
assist  in  the  understanding  of  the  course  of  a  pencil  of  rays 
after  they  have  passed  through  an  astigmatic  cornea,  those  rays 
belonging  to  the  horizontal  and  vertical  meridians  being  chiefly 
considered. 

At  A  neither  vertical  (v,  v')  nor  horizontal  {]i,  h')  rays  have 
yet  been  united  at  their  foci,  but  the  vertical  rays  are  the  nearest 

Fig.  30. 


to  their  focus  ;  and,  therefore,  the  appearance  which  the  pencil 
of  rays  would  give,  if  caught  here  on  an  intercepting  screen,  is  an 
oval  with  its  long  axis  horizontal.  At  B  the  vertical  rays  have 
met  at  their  focus,  but  the  horizontal  rays  not  as  yet  at  theirs, 
and  the  result  is  therefore  a  horizontal  straight  line.  At  C  the 
vertical  rays  are  diverging  again  from  their  focus,  and  the  hori- 
zontal rays  have  still  not  come  to  theirs.  At  D  the  same  condi- 
tions exist,  only  a  little  further  on,  where  the  one  set  of  rays  is 
diverging,  the  other  still  converging,  but  each  at  the  same 
angle  ;  hence  the  shape  of  the  figure  is  round.  At  F  the  hori- 
zontal rays  have  met,  and  the  result  is  a  vertical  straight  line. 
At  G  both  sets  of  rays  are  divergent,  and  the  figure  is  an  oval 
with  the  long  axis  perpendicular. 

There  are  various  kinds  of  regular  astigmatism,  according  to 


ASTIGMATISM.  41 

the  position  of  the  two  principal  foci  with  reference  to  the  retina, 
as  follows  : — 

1.  Simple  Hypermetropic  Astigmatism. — When  the  focus  (V, 
Fig.  31)  of  the  vertical  rays  is  situated  on  the  retina  (emmetropia 
in  that  meridian),  while  that  CH)  of  the  horizontal  rays  lies 
behind  the  retina  (hypermetropia  in  that  meridian). 

Fig.  31.  Fig.  32. 


2.  Compound  Hypermetropic  Astigmatism. — When'the^foci  of 
both  sets  of  rays  is  behind  the  retina,  that  (H,  Fig.  32)  of  the 
horizontal  rays  further  back  than  that  (V)  of  the  vertical 
rays. 

3.  Simple  Myopne  Astigmatism. — When  the  focus  (H,  Fig.  33) 
of  the  horizontal  rays  is  situated  on  the  retina  (emmetropia  in 

Fig.  33.  Fig.  34. 


that  meridian),  while  the  focus  (V)  of  the  vertical  rays  is  situ- 
ated in  front  of  the  retina. 

4.  Compound  Myopic  Astigmatism. — When  the  foci  of  both 
sets  of  rays  are  situated  in  front  of  the  retina,  but  further 
forward  in  the  case  (V,  Fig.  34)  of  the  vertical  rays. 

5.  Mixed  Astigmatism. — When  the  focus  (H,  Fig.  35)  of  the 

4 


42  DISEASES   OF   THE   EYE. 

horizontal  rays  falls  behind  the  retina  (hypermetropia  in  that 

meridian),  and  the  focus  (V)  of  the 
vertical  rays  in  front  of  the  retina 
(myopia  in  that  meridian). 

Symptoms  of  Astigmatism.  —  We 
may  conclude  that  an  individual  is  as- 
tigmatic if  he  sees  horizontal  (or  ver- 
tical) lines,  such  as  the  horizontal  por- 
tions of  Roman  capital  letters,  or  the 
horizontal  lines  in  music,  distinctly, 
while  the  vertical  (or  horizontal)  lines  seem  indistinct.  We  have 
such  a  complaint,  for  example,  when  the  retina  is  situated  at  the 
focus  of  the  parallel  rays  passing  through  the  vertical  meridian 
of  the  cornea. 

Suppose  an  eye  to  be  emmetropic  in  the  vertical  meridian, 
and  ametropic  in  the  horizontal  meridian.  We  must  first  con- 
sider how  a  point  will  be  seen  by  such  an  eye.  The  rays  of 
light  emitted  from  the  point  and  passing  through  the  horizontal 
meridian  will  not  be  brought  to  a  focus  on  the  retina,  but  will 
produce  a  blurring  of  the  retinal  image  of  the  point  at  each 
side ;  while  the  vertical  rays  will  unite  on  the  retina,  and,  conse- 
quently, the  point  will  appear  distinctly  defined  above  and  below. 
A  line  may  be  regarded  as  a  number  of  points,  and,  in  order 
to  understand  how  lines  will  be  seen  by  an  astigmatic  eye  such 
as  the  above,  it  is  only  necessary  to  arrange  a  number  of  points 
in  vertical  and  horizontal  lines — as  at  a  and  b  in  Fig.  36.  It  is 
evident  at  once  from  mere  inspection  that  the  horizontal  line 
will  appear  distinct,  because  the  rays  which  diverge  from  each 
point  of  the  latter  in  a  vertical  plane,  i.e.,  at  right  angles  to  the 
direction  of  the  line,  are  brought  to  a  Yig.  36. 

focus  on    the    retina ;  while    those    rays  ^^ 

diverging  in  a  horizontal  plane,  although 
not  meeting  on  the  retina,  do  not  render 
the  picture  of  the  line  indistinct,  because  ^^^ 

the  diff'usion  images  resulting  from  them  0C» 

exist  in  the  horizontal  direction,  and,  consequently,  cover  or 


ASTIGMATISM.  43 

overlap  each  other  on  the  horizontal  line,  and  therefore  are  not 
seen.     At  the  ends  of  the  line  only  (6,  Fig.  37)  do  the  diffusion 
images  cause  a   "  fuzziness,"   or   make   the 
line  seem  longer  than  it  is.     In  this  case  a  ^^' 

vertical  line  (a,  Figs.  36  and  37)  seems  in-  ^^ 

distinct ;  because,  the   horizontal   meridian  ^^ 

being  out  of  focus,  the  diffusion  images  ex-  ^KK^m^mm^Bsm  5 
isting  in  that  direction  are  very  apparent,  ^J 

as  they  do  not  overlap.     On  the  other  hand,  ^^ 

in  order  to  see  a  vertical  stripe  accurately,  it  is  necessary  only 
that  the  rays  diverging  in  a  horizontal  plane  should  have  their 
focus  on  the  retina ;  and,  therefore,  if  an  individual  can  only 
see  vertical  lines  distinctly  at  6  metres,  we  know  that  his  eye  is 
emmetropic  in  the  horizontal  meridian  (and  probably  myopic  in 
the  vertical  meridian).  We  do  not,  however,  hear  this  com- 
plaint as  often  as  might  be  expected,  because  simple  astigmatism 
is  not  so  common  as  one  or  other  of  the  compound  forms. 

Astigmatic  people  do  not  generally  see  very  distinctly,  either 
at  long  or  at  short  distances. 

Even  in  hypermetropic  astigmatism  the  book  is  very  often 
brought  close  to  the  eyes,  in  order,  by  increasing  the  size  of  the 
retinal  image,  to  make  up  for  its  indistinctness. 

Astigmatic  individuals  frequently  suffer  much  from  headache, 
due  to  constant  effort  to  see  distinctly,  and  we  cure  the  headache 
when  we  correct  the  astigmatism. 

It  has  been  stated  that  epilepsy,  if  not  capable  of  being  pro- 
duced by  refractive  errors,  especially  astigmatism,  in  persons 
with  stable  brains,  may  sometimes  have  such  errors  as  its  excit- 
ing cause  where  there  is  already  a  predisposition  to  the  disease. 
But  the  crucial  test  of  the  correctness  of  this  view — namely,  a 
cure  of  the  epilepsy  by  correction  of  the  error  of  refraction  with 
glasses — is  still  wanting. 

All  these  signs  and  symptoms  appertain  more  to  the  rather 
high  degrees  of  astigmatism.  Slighter  degrees  may  cause  no 
annoyance  beyond  some  indistinctness  of  vision ;  and,  indeed, 
slight   degrees   of  hypermetropic   astigmatism   often   pass   un- 


44  DISEASES   OF   THE    EYE. 

noticed  until  late  in  life,  when  the  accommodation  begins  to 
fail. 

We  are  often  led  to  suspect  and  to  seek  for  astigmatism  when, 
in  examining  the  refraction  with  spherical  glasses,  we  are  able 
to  bring  about  some  improvement  of  vision,  but  cannot  obtain 
normal  V.  with  any  glass,  while  there  is  no  organic  disease  to 
account  for  the  defect.  Also,  if,  in  examining  with  spherical 
glasses,  we  find  V.  benefited  equally  by  several  glasses  of  con- 
siderable difiference  in  power,  even,  perhaps,  by  convex  as  well 
as  by  concave  glasses. 

The  ophthalmoscope  affords  us  an  admirable  means  of  diag- 
nosing astigmatism  and  of  determining  its  amount.  Just  as  the 
astigmatic  eye  cannot  see  horizontal  and  vertical  lines  equally 
well  at  the  same  moment,  so  is  an  observer  unable  to  see  both 
the  vertical  and  horizontal  vessels  in  the  retina  of  the  eye  simul- 
taneously, but  must  alter  his  accommodation  to  be  able  to  see 
first  the  one  set  and  then  the  other. 

A  comparison  of  the  shape  of  the  optic  papilla,  as  seen  in  the 
upright  and  in  the  inverted  images,  also  gives  a  clue  to  the 
presence  of  astigmatism.  Inasmuch  as  the  fundus  oculi  is  very 
much  magnified  in  the  upright  image  by  the  dioptric  media 
through  which  it  is  seen,  and  as  this  enlargement  is  greater  in 
the  direction  of  the  meridian  of  shortest  focus  (meridian  of 
highest  refraction),  which  is  most  commonly  the  vertical 
meridian,  a  circular  object  such  as  the  papilla  will  seem  to  be 
of  an  oval  shape  with  its  long  axis  vertical.  But  in  the  inverted 
image,  in  the  meridian  of  highest  refraction,  the  image  lies 
nearer  the  convex  lens  than  in  the  meridian  of  lowest  refraction, 
and,  hence,  is  much  less  magnified  in  the  former  than  in  the 
latter  meridian ;  and  here,  consequently,  the  round  optic  papilla 
is  seen  as  an  oval  with  its  long  axis  horizontal.  Sometimes  the 
papilla  is  really  of  an  oval  shape,  and  not  round,  and  then  the 
diagnosis  is  readily  made  by  observing  that  in  one  image  it  is  seen 
as  an  oval,  while  in  the  other  image  it  is  circular.  Care  must 
be  taken  in  the  indirect  method  not  to  hold  the  lens  obliquely, 
as  this  would  be  sufficient  to  make  a  circular  disc  appear  oval, 


ASTIGMATISM.  45 

the  long  axis  of  the  oval  being  in  the  direction  of  the  axis  round 
which  the  lens  is  rotated.  The  determination  of  the  degree  of 
astigmatism  can  also  be  accomplished  with  the  ophthalmoscope, 
and  will  be  treated  of  in  the  next  chapter. 

The  Estimation  of  the  Degree  of  Astigmatism,  and  its  Cor- 
rection.— It  is  evident  that,  to  correct  astigmatism,  the  ordinary 
spherical  lenses  would  be  of  little  use,  for  they  affect  the  refrac- 
tion of  the  light  passing  through  them  equally  in  every  direc- 
tion. We  employ,  therefore,  what  are  termed  cylindrical  lenses, 
ground  in  a  peculiar  way,  which  refract  light  in  one  direction 
only,  viz.,  that  corresponding  to  their  curvatures  and  at  right 
angles  to  their  axes.  The  rays  which  pass  through  these  lenses 
in  a  direction  corresponding  to  their  axes  are  not  refracted,  but 
pass  on  without  deviation  as  they  would  do  through  a  piece  of 
plane  glass. 

Although  astigmatism  is  nowadays  almost  universally  esti- 
mated by  means  of  the  ophthalmoscope,  yet,  in  order  to  give  the 
student  a  clear  idea  of  the  matter  in  the  simplest  way,  I  shall 
here  describe  a  subjective  method  for  its  estimation,  while  its 
objective  estimation  by  aid  of  the  ophthalmoscope  will  be  treated 
of  in  the  next  chapter. 

Simple  Astigmatism. — If,  now,  a  case  come  before  us  in  which 
we  suspect  astigmatism,  we  place  Snellen's  Sunrise  (_vide  diagram 
at  end  of  book),  or  some  such  diagram,  at  6  metres  from  the  eye 
— the  other  eye  being  excluded — and  inquire  of  the  patient 
whether  there  be  any  line  which  he  sees  much  more  distinctly 
than  the  others,  and  can  trace  further  towards  the  central 
point.  If  that  be  so,  we  know  that  he  is  emmetropic  in  the 
meridian  at  right  angles  to  that  line,  provided  his  accommoda- 
tion be  at  rest,  and  ametropic  in  the  meridian  corresponding 
to  that  line. 

In  case  the  horizontal  line  below  at  each  side  be  the  distinct 
one,  the  eye  is  emmetropic  in  the  vertical  meridian,  and  prob- 
ably hypermetropic  in  the  horizontal  meridian,  because  the 
latter   is   generally  that   of  least   curvature.     Consequently,  a 


46  DISEASES   OF   THE    EYE. 

convex  cylindrical  lens,  held  with  its  curvature  horizontally 
(axis  vertical)  before  the  eye,  will  correct  the  defect.  The 
highest  convex  cylindrical  glass  which  gives  the  patient  the 
best  possible  distant  vision  will 'be  the  correcting  glass.  This 
is  a  case  of  Simple  Hypermetropic  Astigmatism  (As.  H.).  If 
the  lens  required  he  -{-  2  T)  Cyl.  it  would  be  As.  H.  2  D ;  and 
in  prescribing  for  the  optician  we  should  write  "  -)-  2  D  Cyl. 
Ax.  Vert." 

If  the  central  vertical  line  be  the  distinct  one,  then  em- 
metropia  exists  in  the  horizontal  meridian,  and  probably,  there- 
fore, myopia  in  the  vertical  meridian  ;  and  a  concave  cylindrical 
lens  held  before  the  eye  with  its  curvature  vertical  (axis  hori- 
zontal) will  correct  the  defect.  The  lowest  concave  cylindrical 
lens,  which  gives  the  patient  the  best  possible  distant  vision,  will 
be  the  correcting  lens.  This  is  a  case  of  Simple  Myopic  Astig- 
matism (As.  M.).  If  the  lens  be  —  2.5  Cyl.  it  would  be  As.  M. 
2.5  D ;  and  for  the  optician  we  should  write,  "  —  2.5  D  Cyl. 
Ax.  Horiz." 

I  advise  the  reader  to  make  now  a  few  experiments  for 
himself  with  cylindrical  lenses,  by  means  of  which  he  can  pro- 
duce artificial  astigmatism  in  his  own  eye.  If  he  hold  a  -f-  1-0 
Cyl.  before' his  eye,  w^ith  its  axis  horizontal,  it  gives  a  myopia  of 
1.0  D  to  the  vertical  meridian  of  the  eye,  while  the  horizontal 
meridian  remains  emmetropic ;  and,  consequently,  he  will  see 
the  central  vertical  line  of  the  diagram  distinctly,  while  the 
horizontal  lines  will  be  indistinct.  By  placing  a  —  1.0  Cyl.  with 
its  axis  vertical  before  the  eye,  in  addition  to  the  -f  1-0  Cyl., 
the  artificial  astigmatism  produced  by  the  latter  is  corrected, 
and  the  whole  diagram  becomes  distinct.  Every  other  kind  and 
degree  of  astigmatism  can  be  similarly  represented  by  lenses,  and 
similarly  corrected. 

Compound  Astigmatism. — If  no  line  be  very  distinctly  seen, 
then  we  may  commence  our  examination  with  Snellen's  Distance 
Test-Types,  and  test  in  the  ordinary  way  with  spherical  lenses, 
until  we  find  that  one  which  gives  the  best  distant  vision.     This 


H.  4  D  +  H.  1  D 


ASTIGMATISM.  47 

we  place  in  a  spectacle  frame  before  the  eye,  and  proceed,  as 
already  explained,  to  ascertain  the  mer-  h.  4  d 
idians  of  greatest  and  least  curvature  of 
the  cornea.  If  the  spherical  lens  be  -[-  4 
D,  and  with  it  the  horizontal  lines  in  the 
sunrise  diagram  be  the  most  distinct,  then 
the  vertical  meridian  is  shown  to  be  cor- 
rected, and  the  eye  is  probably  still  hypermetropic  in  the  hori- 
zontal meridian,  and  requires  a  -{-  cylindrical  lens  with  its  axis 
vertical,  in  addition  to  the  spherical  lens,  to  correct  the  entire 
defect.  Suppose  this  cylindrical  lens  be  found  to  be  -[-  1  D 
Cyl.,  then  the  H.  in  the  horizontal  meridian  will  be  shown  to  be 
5  D,  and  the  astigmatism  to  be  1  D. 

The  latter  noted  down  would  be  of  little  practical  value,  and 
therefore  we  prefer  to  write  in  our  note-books  the  factors  of 
the  Astigmatism,  thus :  "  H,  4  D  +  As.  H.  1  D  Horiz." ;  or, 
as  for  the  optician,  "  -j-  4  D  Sph.  O  +  1  D  Cyl.  Ax.  Vert."* 
This  is  Compound  Hypermetropic  Astigmatism. 

In  an  analogous  way  we  examine  for  Compound  Myopic  As- 
tigmatism, in  which  every  meridian  is  myopic,  but  the  vertical 
more  so  than  the  others. 

Mixed  Astigmatism. — Lastly,  we  come  across  cases  in  which 
both  concave  and  convex  spherical  lenses  produce  a  certain 
amount  of  improvement,  but  neither  give  full  vision.  Placing 
then  one  or  other  before  the  eye  in  the  spectacle  frame,  the 
examination  is  proceeded  with  by  aid  of  Snellen's  sunrise.  We 
ascertain,  for  example,  what  is  the  lowest  concave  spherical 
lens  which  will  bring  out  one  horizontal  ray  distinctly  ;  let  this 
be  —  3D;  we  have  then  myopia  of  3  D  in  the  vertical  meridian. 
Now,  having  removed  the  —  lens,  we  find  what  is  the  highest 
convex  lens  which  will  bring  out  one  vertical  line  distinctly ; 
let  it  be  -f  5  D;  this  indicates  hypermetropia  of  that  amount  in 
the  horizontal  meridian.  We  may  correct  such  a  case  in  either 
of  two  ways — (a)  By  a  Sph.  —  3D,  which  will  correct  the  ver- 

*  The  sign  o  indicates  "  combined  with." 


48  DISEASES   OF   THE   EYE. 

tical  meridian,  but  will  increase  the  hypermetropia  in  the  hori- 
j^  3j^  zontal   meridian  by  3  D,  making  it  8  D, 

which  can  then  be  corrected  by  combining 
a  cylindrical  lens  of  -f  8  D,  axis  vertical, 


-H.  5D 


wi 


ith  the  above  spherical  lens,  (b)  By  a 
spherical  -\-  5  D,  which  will  correct  the 
horizontal  meridian,  but  will  increase  the 
myopia  in  the  vertical  meridian  to  8  D,  necessitating  the  combi- 
nation of  a  —  cyl.  lens  of  that  number,  with  the  -\-  5  D  Sph. 
For  reading,  writing,  etc.,  an  over-correction  of  the  horizontal 
meridian  with  -f  8  D  Cyl.,  thus  rendering  the  eye  myopic  3  D 
in  every  meridian,  and  enabling  the  patient  to  read  at,  or  near, 
his  far  point,  might  be  the  most  suitable  arrangement. 

As  it  is  necessary,  in  order  to  test  the  degree,  etc.,  of  astigma- 
tism accurately,  that  the  accommodation  be  at  rest,  it  is  desir- 
able, before  the  examination  for  any  of  the  hypermetropic  forms, 
to  instil  atropine  into  the  eye. 

Lental  Astigmatism. — Disturbances  of  vision  due  to  astigma- 
tism often  make  their  appearance  for  the  first  time  at  middle 
age,  or  even  later,  and  are  then  apt  to  be  mistaken  for  ambly- 
opia. In  such  cases  the  cornea  has  been  astigmatic  all  through, 
but  the  defect  has  been  masked  by  a  compensating  astigmatism 
of  the  crystalline  lens,  produced  by  an  unequal  accommodative 
contraction  of  the  ciliary  muscle.  When,  now,  as  life  advances, 
the  amplitude  of  accommodation  diminishes,  the  power  of  the 
ciliary  muscle  to  produce  this  active  compensatory  lental  astig- 
matism also  diminishes,  and  finally  disappears;  and,  conse- 
quently, the  corneal  astigmatism  comes  to  the  front.  Or,  in 
astigmatic  individuals  the  astigmatism  may  alter  in  degree  at 
this  time  of  life.  Under  atropine,  too,  astigmatism  may  appear, 
the  existence  of  which  was  not  previously  known.  This  is 
termed  active,  or  dynamic,  lental  astigmatism. 

Passive,  or  static,  lental  astigmatism  is  due  to  irregularity  in 
the  shape  of  the  unaccommodated  lens,  and,  as  the  case  may  be, 
gives  rise  to  disturbances  of  vision  similar  to  those  caused  by 
corneal  astigmatism  ;  or,  it  increases  existing  corneal  astigmatism  ; 


ANISOMETROPIA.  49 

or,  it  more  or  less  completely  compensates  the  corneal  astigma- 
tism. It  has  no  clinical  importance  which  does  not  attach  to 
corneal  astigmatism. 

Irregular  Astigmatism. 
In  irregular  astigmatism  the  refraction  of  the  eye  differs,  not 
only  in  different  meridians  of  the  eye,  but  even  in  different 
parts  of  one  and  the  same  meridian.  This  is  frequently  due  to 
irregularities  on  the  surface  of  the  cornea,  the  result  of  former 
ulcers,  and  also  sometimes  to  irregular  refracting  power  in 
different  parts  of  the  crystalline  lens.      It  cannot  be  corrected. 

Anisometropia 
means  a  difference  in  the  refraction  of  the  two  eyes,  one  being 
myopic,  hypermetropic,  or  astigmatic,  while  the  other  is  emme- 
tropic, or  ametropic  in  a  way  different  from  its  fellow.  So  long 
as  the  difference  in  refraction  is  but  slight,  say  1  D  or  1.5  D,  it 
is  generally  possible  to  give  the  correcting  glass  to  each  eye. 
When  the  difference  is  considerable,  it  is  often  impossible  to 
fully  correct  each  eye,  because  binocular  vision  having  never 
really  existed,  the  patients  are  unable  to  tolerate  the  presence  of 
a  clear  image  on  each  retina.  We  must  then  be  content  with 
correction  of  the  least  ametropic  eye,  or  of  that  one  which  has 
the  best  vision  ;  or,  we  may  partially  correct  the  most  ame- 
tropic, and  fully  correct  the  least  ametropic  eye.  Each  such 
case  must  be  dealt  with  as  it  permits. 


ANOMALIES  OF  ACCOMMODATION. 

Presbyopia. 
This  is  a  diminution  in  the  amplitude  of  accommodation, 
which  commences  at  an  early  age,  and  is  due  solely  to  natural 
changes  taking  place  slowly  in  the  crystalline  lens.  It  might 
not,  therefore,  strictly  speaking,  be  considered  as  an  anomaly. 
The  power  of  accommodation  commences  to  diminish  in   early 


50 


DISEASES    OF    THE    EYE. 


childhood,  the  near  point  beginning  then  to  recede  from  the  eye. 
Bonders  it  was  who  first  discovered  this  fact,  and  ascertained 
the  laws  which  govern  the  progressive  decrease  of  accommoda- 
tive power.  He  designed  the  accompanying  diagram  (Fig.  38), 
which  illustrates  the  decrease  from  the  tenth  year  of  age,  and 
indicates  the  amplitude  of  accommodation  at  different  ages. 

The  numbers  along  the  upper  horizontal  line  refer  to  the  ages, 
those  along  the  left-hand  perpendicular  line   to  the  dioptrics. 

Fig.  38. 
r     rr    f»    9s    y>   _s^    o    ^.r   ^f^>    .r.r    n    ef     r?     tt  s, 


rv- 

1 

^^ 

\, 

v 

\ 

<' 

X 

■10 

\ 

fi 

\ 

S 

\ 

K 

\ 

f 

\ 

jr 

\ 

N 

j^ 

N 

V 

.1 

X 

s. 

? 

N 

\ 

s^ 

0 

N 

-. 

Y 

^~-7~-Civ^ 

P 

P 

T*^ 

'^si— 

? 

/, 

./ 

1           1 

1 

ZJ 

The  shorter  curve  shows  the  refraction  of  the  eye  when  in  a  state 
of  rest.  This  is  unchanged  until  the  55th  year,  when  it  begins  to 
diminish;  the  emmetropic  eye  then  becoming  hypermetropic, 
the  hypermetropic  eye  more  hypermetropic,  and  the  myopic  eye 
less  myopic.  The  curve  j)  p  shows  the  positive  refracting  power 
of  the  eye  corresponding  to  the  punctum  proximum,  and  its 
gradual  diminution  as  life  advances ;  and  how,  at  the  age  of  ^b, 
it  becomes  even  less  than  the  minimum  refraction   in   former 


PRESBYOPIA.  61 

years.  The  two  curves  meet  at  the  age  of  73,  and  then  all 
power  of  accommodation  ceases.  The  number  of  dioptrics 
included  between  the  two  curves  on  the  vertical  line  correspond- 
ing to  any  given  age  represent  the  amplitude  of  accommodation 
at  that  age  ;  e.  g.,  at  30  years  of  age  the  amplitude  is  7  D  ;  at 
50  years  it  is  only  2.5  D.  The  amplitude  of  accommodation  is 
the  same  at  the  same  age  in  all  forms  of  ametropia,  as  well  as  in 
emmetropia. 

The  cause  of  presbyopia  lies  chiefly  in  a  progressive  change  in 
the  crystalline  lens,  which  becomes  less  elastic,  and  more  homo- 
geneous in  its  different  layers,  and  refracts  light  less  strongly 
than  before.  In  more  advanced  life  diminished  energy  of  the 
ciliary  muscle  probably  becomes  a  second  factor  in  the  produc- 
tion of  presbyopia. 

The  near  point  gradually  recedes  from  the  eye,  until  it  reaches 
a  distance  beyond  that  at  which  the  person  usually  reads,  writes, 
sews,  etc.  Employments  of  this  kind  then  become  difficult,  be- 
cause the  retinal  images  are  too  small  to  be  clearly  discerned, 
owing  to  the  increased  distance  at  which  the  work  must  be  held 
from  the  eye ;  and,  in  order  to  make  up  for  this  smallness  of  the 
images,  the  individual  is  often  seen  to  improve  their  brilliancy 
by  procuring  stronger  light. 

Presbyopia  is  usually  said  to  be  present  when  the  near  point 
lies  at  more  than  22  cm.  from  the  eye,  and  we  correct  it  by  giv- 
ing such  a  convex  glass  for  reading,  etc.,  as  will  bring  the  near 
point  back  to  22  cm.  Now,  in  order  to  see  at  that  distance,  a 
positive  refracting  power  ( j?)  of  (-^^  =)  4.5  D  is  necessary ; 
and,  if  the  eye  have  not  so  much  positive  refraction,  a  convex 
glass  must  be  given  to  it  of  such  power  as  will  bring  jj  up  to  4.5 
D ;  and  this  lens  is  the  measure  of  the  presbyopia.  At  the  age 
of  40  (vide  Donders'  diagram.  Fig.  38)  the  eye  possesses  a  posi- 
tive refraction  of  just  4.5  D  ;  and,  therefore,  from  this  age  pres- 
byopia {-pia^uq^^  uiili)  is  said  to  commence  in  emmetropic  eyes. 
The  presbyopia,  then,  is  equal  to  the  difference  between  the 

*  An  old  man. 


52 


DISEASES   OF   THE   EYE. 


positive  refracting  power  possessed  by  the  eye  and  4.5  D,  and 
the  number  thus  found  is  the  correcting  glass  for  the  pres- 
byopia. 

It  is  important  for  the  patient's  comfort  that  in  prescribing 
glasses  for  presbyopia,  if  there  be  any  hypermetropic  astigma- 
tism present,  it  should  be  corrected  by  the  suitable  -|-  cylinder 
lens  added  to  the  spherical  glasses. 

The  following  table  indicates  the  presbyopia  of  the  emme- 
tropic eye : — 


Age. 

p.  required. 

p.  existing. 

Presbyopia. 

40 

4.5 

4.5 

0 

45 

4.5 

3.5 

1.0 

60 

4.5 

2.5 

2.0 

55 

4.5 

1.5 

3.0 

60 

4.5 

0.5 

4.0 

65 

4.5 

0.25 

4.25 

70 

4.5 

-1.0 

5.5 

75 

4.5 

-1.75 

6.25 

80 

45 

-2.5 

7.0 

It  is  hardly  necessary  to  point  out  that  presbyopia  comes  on 
at  a  much  earlier  age  in  hypermetropes  than  in  emmetropes ; 
while  in  myopes  its  advent  is  postponed ;  or,  in  the  higher 
degrees  of  myopia,  it  may  not  come  on  at  all.  The  hyperme- 
trope  of  3  D  would  be  presbyopic  at  the  age  of  27  ;  because,  in 
order  to  arrive  at  the  4.5  D  of  positive  refraction  required,  he 
must  have  an  amplitude  of  accommodation  of  (3  D  -j-  4.5  D) 
7.5  D,  and  this  he  has  only  up  to  that  age  {vide  Fig.  38). 

The  myope  of  4.5  D  can  get  along  until  something  over  60 
years  of  age  without  any  glass  for  reading  (vide  above  Table). 
At  65,  if  he  were  emmetropic,  he  would  have  a  presbyopia  of 
4.25;  consequently,  he  will  now  require  a  -{-  glass  of  only  0.25  D. 

Presbyopia  must  not  be  mistaken  for  slight  paralysis  of 
accommodation.  They  are  distinguished  by  the  fact  that,  in 
the  former,  the  amplitude  of  accommodation  corresponds  to  the 
age  of  the  patient  as  given  in  Bonders'  table. 


paralysis  of  accommodation.  53 

Paralysis  of  Accommodation. 

This  may  be  partial  or  complete,  and  one  or  both  eyes  may 
be  affected.  It  is  usually  combined  with  paralysis  of  the 
sphincter  iridis  (mydriasis),  and  the  condition  is  then  called 
ophthalmoplegia  interna  ;  but  it  is  also  seen  without  paralysis 
of  the  sphincter,  and  either  alone  or  with  paralysis  of  some 
of  the  orbital  muscles  supplied  by  the  third  pair — rarely  with 
paralysis  of  the  external  rectus. 

The  Symptoms  are  similar  to  those  of  presbyopia,  and  give 
inconvenience  to  the  patient  according  to  the  state  of  his  refrac- 
tion. If  he  be  emmetropic,  his  distant  vision  continues  good, 
while  his  vision  for  near  work  is  much  impeded.  If  he  be 
hypermetropic,  as  he  requires  his  accommodation  for  distant 
objects,  vision  for  distance  is  interfered  with,  and,  still  more  so, 
vision  for  near  objects.  If  he  be  myopic,  vision  is  less  affected 
than  in  either  of  the  other  forms  of  refraction  ;  indeed,  if  he  be 
very  near-sighted,  being  able  to  see  near  objects  at  his  far  point, 
he  may  suffer  little  or  no  inconvenience. 

Micropsia  is  a  common  symptom  in  cases  of  partial  paralysis 
of  accommodation,  and  is  due  to  the  fact  that  the  great  effort 
of  the  defective  accommodation  gives  the  sensation  of  the  object 
being  much  nearer  to  the  eye  than  it  really  is. 

Causes. — The  most  common  cause  of  paralysis  of  accommoda- 
tion is  the  action  of  atropine ;  but  it  is  also  the  result  of,  or  is 
attendant  upon,  various  diseases.  It  is  one  of  the  symptoms  of 
paralysis  of  the  third  nerve ;  it  may  be  due  to  exposure  to  cold  ; 
or  it  may  depend  upon  syphilis,  syphilitic  periostitis  at  the  sphe- 
noidal fissure,  syphilitic  gumma,  or  syphilitic  inflammation  of 
the  nerve  itself. 

In  cases  of  double  paralysis  of  accommodation  a  central  cause 
must  often  be  looked  for.  Paralysis  of  accommodation  and 
mydriasis  are  sometimes  forerunners,  by  many  years,  of  serious 
mental  derangement. 

Diphtheria  is  a  frequent  cause  of  paralysis  of  accommoda- 
tion, usually  without,  but  sometimes  with,  mydriasis.     The  onset 


54  DISEASES   OF   THE   EYE. 

occurs  most  commonly  some  weeks  after  the  throat  affection, 
which  need  not  have  been  of  a  severe  character.  Indeed,  the 
faucial  attack  may  haye  had  no  apparent  diphtheritic  character, 
and  may  have  been  so  slight  as  almost  to  have  escaped  the 
notice  of  the  patient.  The  lesion  in  these  cases  is  probably  a 
central  one,  and  the  evidence  points  to  miliary  extravasations 
of  blood  in  the  floor  of  the  third  ventricle  ;  but  there  are  those 
who  hold  that  the  paralysis  is  due  to  a  poison,  that  it  is  a  toxic 
paralysis. 

During  the  recent  epidemics  of  influenza  {la  grippe)  cases  of 
paralysis  of  accommodation  were  recorded,  occurring  some  of 
them  during  the  acute  stage  and  others  during  convalescence. 
They  all  recovered  except  one,  which  seems  to  have  gone  on  to 
bulbar  paralysis.* 

Paralysis  of  accommodation  in  middle  life  may  be  due  to 
diabetes,  and  should  make  us  suspicious  of  the  presence  of  this 
disease. 

Blows  on  the  eye  are  apt  to  cause  paralysis  of  accommodation, 
usually  with  mydriasis. 

The  Treatment  depends,  of  course,  upon  the  cause  of  the 
paralysis.  The  instillation  of  a  1%  solution  of  sulphate  of 
eserine,  or  of  muriate  of  pilocarpine,  may  be  employed  in  all 
cases,  and  will  at  least  produce  temporary  improvement  of  sight ; 
but  it  can  hardly  be  said  to  assist  in  the  cure,  except,  perhaps, 
in  slight  diphtherial  cases.  Iodide  of  potassium  and  mercury 
are  indicated  in  syphilitic  cases,  and  iodide  of  potassium  and 
salicylate  of  sodium  in  rheumatic  cases.  The  prognosis  in  these 
cases  must  be  very  guarded,  as  it  often  happens  that  recovery 
does  not  take  place.  Where  cure  does  not  result,  the  patient 
may  be  enabled  to  make  better  use  of  his  eye,  or  eyes,  by 
means  of  a  convex  glass,  or  spectacles ;  but,  in  this  matter,  each 
case  must  be  dealt  with  for  itself — no  general  rule  can  be  laid 
down. 

In   diphtheritic  cases  a  general   tonic  treatment,  especially 


*  Uhthoff  in  Deutsche  Med.  Wochenschr.,  No.  10,  1890. 


SPASM    OF   ACCOMMODATION.  55 

iron,  is  indicated  ;  and  here  the  prognosis  is  invariably  favor- 
able. 

Accommodative  Asthenopia 

has  been  already  treated  of  under  the  head  of  Hvpermetropia 
(p.  30). 

Spasm  of  Accommodation. 

Spasm,  or  cramp,  of  accommodation  in  connection  with  hyper- 
metropia  and  myopia  has  already  been  referred  to.  A  few  cases 
of  acute  spasm  of  accommodation  have  been  reported."^  Occur- 
ring in  an  emmetropic  or  slightly  hypermetropic  eye,  such  a 
spasm  produces  apparent  myopia.  In  some  of  the  cases  there 
was  no  assignable  cause  for  the  spasm,  in  some  it  was  due  to 
overwork,  and  in  one  to  trauma  of  the  cornea.  The  treatment 
is  a  lengthened  course  of  atropine  locally. 


*A.  V.  Graefe,  Archiv  f.  Ophthal.,  vol.  ii,  pt.  2,  p.  308;  Liebreich, 
Archiv  f.  Ophthal.,  vol.  iii,  pt.  1,  p.  259  ;  C.  E.  Fitzgerald,  Trans. 
Ophthal.  Soc,  vol.  v,  p.  311. 


CHAPTER  III. 

THE    OPHTHALMOSCOPE. 

Although  the  dioptric  media  of  an  eye  be  perfectly  clear  and 
normal,  yet  no  detail  of  its  fundus  can  be  discerned  by  the  un- 
aided eye  of  an  observer  who  looks  through  the  pupil,  the  latter 
being  for  him  merely  a  dark  opening.  The  reason  of  this  is, 
that  these  dioptric  media  are  composed  of  a  system  of  convex 
lenses.     To  explain  :  Suppose  the  inside  of  a  small  box  (vide 

Fig.  39. 


Fig.  39)  to  be  blackened,  and  on  its  floor  some  printed  letters 
fastened,  and  a  hole  cut  in  the  lid,  which  is  then  replaced ;  it 
will  be  found  that,  by  aid  of  a  lighted  candle  and  with  a  little 
experimentation,  the  letters  may  be  read  through  the  aperture. 
The  rays  passing  from  the  light  L  into  the  box  through  the 
aperture  illuminate  the  opposite  surface,  and  from  this  surface 
the  rays  a,  b,  and  others,  pass  out  again  through  the  opening, 
and  some  of  them  fall  into  the  observer's  eye  at  E. 

But  if,  in  order  to  make  this  box  represent  an  eye  more  accu- 
rately, we  place  a  convex  lens  immediately  within  the  aperture, 
the  course  of  the  rays  is  altered.     All  the  rays  passing  into  the 

56 


THE   OPHTHALMOSCOPE. 


57 


box  (Fig.  40)  from  L  are  brought  to  a  focus  on  its  opposite  side 
at  m  by  the  convex  lens,  n;  and,  according  to  the  optical  law  of 
conjugate  foci,  all  the  rays  passing  out  from  the  box  meet  again 
at  the  source  of  light,  X,  and  hence  none  of  them  can  be  received 
by  the  eye  (a)  of  the  observer,  nor  can  this  eye  be  placed  in  any 
position  where  it  could  catch  any  of  these  rays ;    for,  if  it  be 

Fig.  40. 


^1 

-  "t^ 

7Z 

m 

placed  anywhere  between  the  aperture  and  L,  it  would  cut  off 
the  light  passing  from  h  into  the  box. 

Helmholtzs  Ophthalmoscope. — If  the  eye  of  the  observer  could 
itself  be  made  the  source  of  light,  the  difficulty  would  be 
solved ;  and,  practically,  this  is  what  Helmholtz   accomplished 


Fig.  41. 


with  his  ophthalmoscope  in  the  year  1851.  The  instrument  he 
invented  was  composed  of  a  number  of  small  plates  of  glass, 
0  (Fig.  41),  from  which  light  from  L  was  reflected  into  the  eye 
E,  and  thus  the  fundus  of  the  latter  illuminated.  From  m  rays 
pass  back  again  by  the  same  course  to  the  ophthalmoscope,  some 
being    reflected   back  to  L;    but  some,  passing    through    the 


58  DISEASES    OF    THE    EYE. 

ophthalmoscope,  and  falling  into  the  observer's  eye  placed  close 
behind  the  instrument  at  a,  form  in  it  an  image  of  m. 

Modern  Ophthalmoscope. — For  the  original  ophthalmoscope  of 
Helmholtz  a  concave  mirror  of  20  cm.  focal  length  with  a  cen- 
tral opening  has  been  substituted.  This  mirror  0  (Fig.  42) 
throws  convergent  rays  into  the  eye  E]  and  these,  being  made 
more  convergent  by  the  refracting  media,  cross  in  the  vitreous 
humor,  and  light  up  part  (a  h)  of  the  fundus.  From  every 
point  of  this  illuminated  surface  rays  are  reflected  back  again 
out  of  the  eye.  If  the  latter  be  emmetropic,  the  rays  from  any 
one   point   become   parallel   on   leaving  it ;  and  some  of  these 

Fig.  42. 


parallel  rays,  passing  through  the  ^aperture  (c)  of  the  ophthal- 
moscope, falljnto  the  observer's  eye,  and,  if  it  be  emmetropic, 
are  brought  to  a  focus  on  its  retina  ;  the  rays  from  m  at  m' , 
those  from  x  at  x\  and  those  from  ij  at  y  ;  and  thus  an  image  of 
the  part  x  m  y  is  formed  on  the  observer's  retina. 

The  foregoing  method  of  examining  with  the  ophthalmoscope 
is  called  The  Direct  Method,  or  The  Examination  of  the 
Upright  Image.  By  it  the  various  parts  of  the  fundus  are  seen 
in  their  natural  positions,  but  much  enlarged  (about  15  diame- 
ters in  the  emmetropic  eye)  ;  and  it  is,  consequently,  very 
valuable  for  examining  minute  details. 

It  is  necessary  for  this  method  that  the  surgeon  should 
approach  his  eye  as  close  as  possible  to  the  eye  under  examina- 


THE    OPHTHALMOSCOPE.  59 

tioD,  in  order  to  receive  as  much  of  the  light  coming  out  of  it  as 
possible. 

It  is  also  necessary  for  this  method  that  the  accommodation 
both  of  the  surgeon's  and  of  the  patient's  eye  be  at  rest,  as 
otherwise  the  rays  coming  from  the  latter  cannot  form  an  image 
on  the  retina  of  the  former,  at  least  if  both  be  emmetropic. 

If  the  patient  exert  his  accommodation,  the  rays  will,  on  leav- 
ing his  eye,  become  convergent,  instead  of  parallel,  and,  falling 
into  the  surgeon's  eye,  will  be  brought  to  a  focus  in  front  of 
his  retina.  If  the  surgeon  exert  his  accommodation,  the  parallel 
rays  from  the  patient's  eye  will  likewise,  on  falling  into  his,  the 
surgeon's,  eye,  be  brought  to  a  focus  in  front  of  his  retina.  And  if 
both  patient  and  surgeon  accommodate,  the  focus  of  the  rays  from 
the  patient's  fundus  oculi  will,  of  course,  lie  still  further  in  front 
of  the  surgeon's  retina.  The  patient's  accommodation  will  be 
relaxed  by  making  him  gaze  at  the  black  wall  behind  the  sur- 
geon's head,  or  his  accommodation  may  be  paralyzed  with 
atropine.  But  atropine  should  never  be  used  unless  absolutely 
necessary,  owing  to  the  inconvenience  it  causes  the  patient. 

Voluntary  relaxation  of  the  accommodation  on  the  part  of 
the  surgeon  is  often  a  matter  of  much  difficulty  to  beginners. 
The  ciliary  muscle,  not  being  a  voluntary  muscle,  is  not  under 
our  direct  control,  and  can  be  influenced  only  in  a  secondary 
way  through  the  convergence  of  the  optic  axes ;  for  this  con- 
vergence is  regulated  by  voluntary  muscles  ( the  internal  and 
external  recti),  and  is  intimately  associated  with  the  effort  of 
accommodation.  With  parallel  optic  axes  our  accommodation 
is  relaxed ;  therefore,  when  we  want  to  relax  our  accommoda- 
tion, we  produce  parallelism  of  our  optic  axes.  This  sounds  easy 
enough ;  yet,  when  the  beginner  approaches  his  eye  close  up  to 
that  of  his  patient,  the  knowledge  that  he  is  so  close  to  the 
object  he  wishes  to  see  renders  the  accomplishment  of  this 
parallelism  and  relaxation  of  accommodation  very  difficult  to 
many. 

It  is  not  easy  to  teach  another  person  how  to  relax  his  accom- 
modation, but  the  following  hint  may  be  of  use.     Take  a  printed 


60  DISEASES   OF   THE    EYE. 

page,  and  hold  it  at  the  ordinary  reading  distance,  so  that  the 
type  may  be  clearly  seen ;  then  gaze  vacantly  at  it,  so  that  the 
type  may  become  indistinct.  The  accommodation  is  now  relaxed, 
and  the  act  is  accompanied  by  a  peculiar  sensation  in  the  eyes. 
When  examining  in  the  erect  image,  cause  this  same  sensation 
to  take  place ;  and  it  may  be  assisted  if,  with  the  eye  which  is 
not  in  use,  the  black  wall  behind  the  patient's  head  be  gazed  at. 

The  Indirect  Method,  or  The  Examination  of  the  Inverted 
Image,  is  employed  in  order  to  obtain  a  more  general  view  of 
the  fundus  than  the  direct  method  admits  of. 

In  addition  to  the  ophthalmoscope,  a  convex  glass  {I,  Fig.  43) 
of  about  14  D   is  here  used.     The  latter  is  held  about  10  cm. 

Fig.   43. 


from  the  eye  {E)  under  examination,  while  the  observer  throws 
the  light  through  it  into  the  eye.  In  passing  through  the  lens 
the  rays  are  made  convergent,  and  this  convergence  is  increased 
by  the  refracting  media,  so  that  the  rays  cross  in  the  vitreous 
humor,  and  light  up  a  portion  of  the  fundus  oculi.  From  any 
points  a  and  h  of  this  illuminated  place  pencils  of  rays  pass  out 
again  from  the  eye,  and,  becoming  parallel,  pass  through  the 
lens,  and  are  united  by  it  at  a'  h';  and  thus  a  real  inverted  image 
is  formed  of  the  part  a  b,  which  image  may  be  seen  by  the  ob- 
server whose  eye  is  placed  behind  0.  The  stronger  the  lens  /, 
the  more  convergent  must  rays  from  the  examined  eye  be  made  ; 
and,  consequently,  the  closer  must  a'  b'  be  to  each  other,  and  the 
smaller  and  brighter  must  be  the  image  formed.     The  weaker 


THE    OPHTHALMOSCOPE. 


61 


the  lens  I,  the  larger  and  less  brilliant  is  the  image,  and  the  less 
annoying  to  the  surgeon  are  the  reflexes  from  the  surfaces  of 
the  lens. 

In  examining  by  the  indirect  method,  the  observer  first  places 
the  upper  edge  of  the  ophthalmoscope  to  his  right  supra-orbital 
margin,  and,  taking  care  that  he  is  looking  through  the  central 
opening  of  the  mirror,  he  reflects  the  light  of  the  lamp  into  the 
patient's  eye  at  a  distance  of  about  50  cm.  A  red  glare  from 
the  fundus  will  then  be  seen  in  the  pupil.  Keeping  the  pupil 
illuminated,  the  convex  14  D,  held  between  the  forefinger  and 
thumb  of  the  surgeon's  left  hand,  is  brought  up  in  front  of  the 
patient's  eye  and  kept  there  in  the  perpendicular  position,  the 

Fig.  44. 


surgeon  steadying  this  hand  with  the  tip  of  the  little  finger  on 
the  patient's  forehead.  The  convex  glass  is  now  removed  just 
far  enough  from  the  patient's  eye  to  cause  the  margin  of  the 
pupil  to  disappear  out  of  the  surgeon's  field  of  vision.  The 
observer  then  ceases  to  look  into  the  eye,  and  fixes  his  gaze  on 
the  convex  glass,  when  the  inverted  image  of  the  fundus  should 
at  once  become  visible — and  will  seem  to  be  situated  in  the 
convex  lens,  although  it  really  is  in  the  air  somewhat  this  side 
of  the  lens. 

The  diagram  (Fig.  44)  serves  to  illustrate  the  effect  of  in- 
version of  the  image. 

The  left  eye  is  seen  in  the  upright  image  in  the  left-hand 
picture,  while  the  same  eye  is  seen  in  the  inverted   image  in 


62  DISEASES   OF    THE    EYE. 

the  right-haiid  picture.  In  the  diagram  the  two  images  are  of 
the  same  size,  for  the  sake  of  convenience  ;  although,  of  course, 
in  reality  the  upright  image  is  much  larger  than  the  inverted 
image.  Moreover,  it  should  not  be  supposed  that  nearly  the 
whole  fundus  oculi,  as  here  represented,  can  be  taken  in  at  one 
view  with  the  ophthalmoscope.  The  portion  visible  with  the 
ophthalmoscope  at  one  moment,  even  in  the  inverted  image,  is 
small ;  so  that  it  is  necessary  to  examine  the  different  regions  in 
detail,  in  order  to  become  acquainted  with  their  condition. 

The  reflex  from  the  surface  of  the  cornea  gives  a  good  deal  of 
annoyance  to  every  beginner.  It  cannot  be  done  away  with  ; 
but,  as  it  moves  in  the  opposite  direction  to  a  motion  of  the 
object  lens,  it  is  possible  to  see  past  it.  The  reflections  from  the 
convex  object-lens  are  also  extremely  annoying,  but  may  be 
removed  to  a  great  extent  from  the  line  of  sight  by  a  slight 
rotation  of  the  lens  on  its  axis.  If  a  very  high  convex  lens,  say 
-}-  20  D,  be  used,  the  reflections  from  it  are  more  disturbing 
than  from  a  lower  number,  say  -J-  14  D. 

To  examine  The  Optic  Nerve,  the  surgeon  sits  in  front  of  the 
patient,  and  directs  him  to  turn  his  eye  somewhat  to  the  nasal 
side  and  slightly  upward  ;  because  the  papilla  is  situated  about 
15°  to  the  inner  side  of  the  posterior  pole  of  the  eye,  and  about 
3°  above  it.  For  instance,  if  the  left  eye  be  examined,  the 
patient  is  to  direct  his  gaze,  without  turning  his  head,  to  the 
right  and  a  little  upward,  say  toward  the  surgeon's  left  ear- 
It  is  well  always  to  seek  out  the  optic  papilla  in  the  first 
instance,  not  only  because  it  is  so  important  a  part  of  the 
fundus  oculi,  but  because,  examining  from  it  toward  the  peri- 
phery, we  are  the  better  able  to  determine  the  locality  of  any 
pathological  alteration. 

Should  the  patient  not  direct  his  gaze  in  such  a  way  as  to 
enable  the  surgeon  to  see  the  optic  papilla  or  other  desired 
region,  it  may  be  brought  into  view  either  by  a  motion  of  the 
surgeon's  head  in  the  opposite  direction,  or  by  a  motion  of  the 
convex  lens  in  the  same  direction,  or  by  a  combination  of  both 
these  manoeuvres. 


THE   OPHTHALMOSCOPE.  63 

The  Macula  Lutea  should  then  be  examined.  It  may  be  seen 
by  directing  the  patient  to  look  straight  at  the  hole  of  the 
ophthalmoscopic  mirror,  for  it  will  then  correspond  with  the 
macula  lutea  of  the  observer's  eye.  It  is  more  readily  seen  in 
the  inverted  than  in  the  upright  image ;  but  its  examination  is 
often  very  difficult,  owing  to  contraction  of  the  pupil  produced 
by  the  strong  light  falling  on  so  sensitive  a  portion  of  the  retina, 
and  by  the  reflections  from  the  surfaces  of  the  cornea  and  crys- 
talline lens,  which  fill  the  area  of  this  contracted  pupil.  It  is, 
therefore,  a  better  plan  to  direct  the  patient  to  look  somewhat 
to  the  side  of  the  eye  under  examination,  e.g.,  to  the  right  side 
of  the  observer's  forehead,  if  the  right  eye  be  under  examination, 
and  then  by  motions  of  the  convex  lens  to  bring  the  macula 
lutea  into  view. 

After  this  The  Periphery  of  the  Fundus  in  every  direction  is 
to  be  examined  by  making  the  patient  look  upward,  downward, 
to  the  right,  to  the  left,  etc. 

Estimation  of  the  Kefraction  by  Aid  of  the 
Ophthalmoscope. 

From  what  has  been  said  with  reference  to  the  Direct  Method 
of  ophthalmoscopic  examination,  it  will  have  become  evident 
that  this  method  affords  a  means  for  determining  the  refraction 
of  the  eye. 

At  a  little  distance  from  the  observed  eye  into  which  light 
from  the  ophthalmoscopic  mirror  is  thrown,  the  surgeon  will  be 
able  to  see  some  of  the  details  of  the  fundus,  if  it  be  either 
myopic  or  hypermetropic ;  but  if  it  be  emmetropic  he  will  be 
unable  to  do  so.  The  reason  for  this  is  that  in  myopia  the  rays 
coming  out  of  the  eye  form  an  inverted  image  at  the  far  point  of 
the  eye  in  the  air,  and  this  image  can  be  seen  by  the  observer 
who  accommodates  his  eye  for  that  point.  In  hypermetropia  the 
rays  coming  out  divergently  from  the  eye  pass  into  the  observer's 
eye,  and,  by  an  effort  of  accommodation  on  his  part,  he  will  see 
an  upright  image  of  the  portion  of  the  patient's  fundus  oculi 
from  which  they  come.     But  in  emmetropia,  inasmuch  as  the 


64  DISEASES    OF   THE    EYE. 

rays  come  out  parallel,  those  from  any  two  points  (m,  n,  Fig.  45) 
at  a  short  distance  from  each  other  in  the  fundus,  on  emerging 
from  the  eye,  diverge  quickly  from  each  other,  and  the  observer 
a  little  way  off  (at  A)  receives  none  of  them  into  his  eye,  or  ob- 
tains only  an  indistinct  image,  or  red  glare.  If  he  go  very  close 
to  the  eye,  he  can  see  details. 

If,  on  the  observer  moving  his  head  from  side  to  side,  the  ves- 
sels, etc.,  of  the  observed  fundus  move  with  him,  the  case  is  one 
of  hypermetropia,  because  the  image  is  an  erect  one,  which  is 
situated  behind  the  plane  of  the  pupil  to  which  it  is  referred.  If 
the  vessels,  etc.,  move  in  the  opposite  direction  to  that  of  the 

Fig.  45. 


observer's  head,  the  observed  eye  is  myopic,  because  there  the 
image  is  inverted  and  in  front  of  the  pupil. 

For  the  quantitative  determination  of  ametropia  a  refraction 
ophthalmoscope  is  required.  This  instrument  provides  a  num- 
ber of  convex  and  concave  lenses,  capable  of  being  brought  into 
position  behind  the  sight-hole  in  rapid  succession  by  a  simple 
mechanism. 

It  is  necessary,  in  the  first  instance,  that  the  surgeon  be  aware 
of  the  nature  of  his  own  refraction. 

If  the  Surgeon  be  Emmetropic,  he  can  see  the  fundus  oculi  of 
an  erametrope  in  the  upright  image  without  any  lens,  provided 
he  go   close   enough  ;  as    the    parallel    rays    coming   from    the 


THE    OPHTHALMOSCOPE.  65 

examined  eye  will  be  focused  on  his  retina,  because  his  eye  is 
adapted  for  parallel  rays. 

In  order  to  see  the  fundus  oculi  of  a  hypermetrope,  without 
any  effort  of  accommodation,  he  must  place  such  a  convex  lens 
behind  his  ophthalmoscope  as  will  render  the  divergent  rays 
coming  from  the  patient's  eye  parallel,  before  they  pass  into  his 
eye.  This  lens  is  the  measure  of  the  patient's  hypermetropia, 
because  it  shows  how  many  dioptries  the  eye  wants  of  being 
emmetropic ;  or,  in  other  words,  so  that  the  rays  coming  from 
it  may  be  made  parallel.  The  lens  which  makes  the  divergent 
rays  coming  from  the  patient's  retina  parallel  would  also  give 
to  parallel  rays  passing  into  the  eye  such  convergence  that  they 
would  meet  on  the  retina,  i.  e.,  it  would  correct  the  hyperme- 
tropia. 

The  emmetropic  surgeon  can,  of  course,  see  the  fundus  oculi 
of  a  hypermetrope  by  the  direct  method  without  the  correcting 
glass  if  he  use  his  accommodation  to  overcome  the  divergence 
of  the  rays,  and  this  is  usually  the  case  in  the  lower  degrees 
of  hypermetropia.  The  surgeon  gradually  relaxes  his  accom- 
modation according  as  he  substitutes  convex  lenses  for  it,  until 
he  reaches  the  strongest  lens  with  which  he  can  distinctly  see 
the  fundus.     This  is  the  correcting  lens. 

To  see  the  fundus  oculi  of  a  myope,  the  emmetropic  surgeon 
must  place  a  concave  glass  behind  his  ophthalmoscope,  in  order 
that  the  convergent  rays  coming  from  the  observed  eye  may 
be  made  parallel  before  they  pass  into  his  eye ;  and  the  lowest 
concave  lens  which  enables  him  to  see  the  fundus  oculi  is  the 
measure  of  the  myopia,  as  showing  by  how  many  dioptries  it 
is  in  excess  of  emmetropia. 

The  emmetropic  surgeon  cannot  possibly  see  the  fundus  oculi 
of  a  myope  without  the  correcting  glass,  as  the  rays  are  brought 
to  a  focus  in  front  of  his  retina,  and  if  he  uses  his  accommoda- 
tion he  merely  makes  them  still  more  convergent.  But,  by 
means  of  an  effort  of  his  accommodation,  he  can  see  the  myopic 
fundus  with  a  lens  which  over-corrects  the  myopia,  and  hence 
6 


66  DISEASES    OF   THE    EYE. 

the  importance  of  selecting  the  weakest  concave  glass  with 
which  the  fundus  is  distinctly  seen. 

If  the  surgeon  be  ametropia,  he  may  either  correct  his  ame- 
tropia by  wearing  the  suitable  lens,  and  then  proceed  as  though 
he  were  emmetropic ;  or  else,  and  which  is  perhaps  the  better 
plan,  he  may  add  or  subtract  the  amount  of  his  ametropia  from 
that  of  his  patient's.     For  example : — 

The  Hypermetropic  Surgeon  of,  say  3  D,  requires  a  -\-  lens  of 
3  D  in  order  to  see  an  emmetropic  fundus  oculi,  this  lens  going 
altogether  to  correct  his  own  defect.  If,  in  order  to  examine 
the  fundus  of  another  eye,  he  requires  a  -f-  lens  of  6  D,  the 
examined  eye  must  be  hypermetropic  3  D,  the  other  3  D 
going  to  correct  the  surgeon's  H.  If  he  be  able  to  see  the 
fundus  oculi  under  observation  without  any  lens,  it  shows  that 
that  eye  has  an  excess  of  refraction  corresponding  to  the  want 
of  refraction  in  his  own  eye — that  is  to  say,  it  is  myopic  3  D. 
If  he  require  a  concave  2  D,  his  want  of  refraction — his  hyper- 
metropia — is  not  enough  by  that  number  of  dioptrics,  and  he 
has  to  do  with  an  eye  which  is  myopic  5  D  (3  D  -|-  2  D). 
Again,  if  he  can  see  the  fundus  distinctly  with  a  +  lens,  say  -f- 
1.0,  which  is  less  than  his  own  correcting  glass,  this  shows  that 
the  eye  he  is  examining  is  myopic,  but  myopic  to  a  lesser  degree 
— in  this  instance  by  1  D— than  he  himself  is  hypermetropic, 
and  the  examined  eye  here  would  be  M.  2.0  D  {i.e.,  3.0  —  1.0). 

If  the  Surgeon  he  Myopic,  say  2  D,  he  requires  a  —  2  D  to 
see  the  fundus  of  an  emmetropic  eye,  this  lens  going  wholly  to 
correct  his  own  ametropia.  If  he  see  the  fundus  with  a  —  7  D, 
the  examined  eye  has  M.  5  D,  because  2  D  has  been  used  in  cor- 
recting the  surgeon's  M.  If  he  be  able  to  see  a  fundus  without 
any  lens,  the  patient  has  H.  2  D,  the  want  of  refraction  in  the 
latter's  eye  compensating  exactly  for  the  excess  of  refraction  in 
the  surgeon's  eye.  If  he  find  it  necessary  to  use  a  +  l^ns  of  7 
D,  it  will  indicate  that  his  excess  of  refraction  is  not  able  to 
make  up  for  the  defect  of  refraction  in  his  patient's  eye,  and 
that  the  latter  has  H.  =  9  D  (2  D  -f  7  D).     If  he  have  to  use 


THE    OPHTHALMOSCOPE.  67 

a  —  lens,  say —  1.0,  which  is  less  than  his  own  correcting  glass, 
this  shows  that  the  eye  he  is  examining  is  hypermetropic  to  a 
lesser  degree — in  this  instance  by  1.0  D — than  he  himself  is 
myopic,  and  the  hvperraetropia  here  would  be  1.0  D  (i.  e.,  2  0 
-  1.0). 

The  Existence  and  Degree  of  Astigmatism  may  be  Determined 
with  the  Ophthalmoscope. — We  know  that  astigmatism  is  present, 
if,  in  the  upright  image,  we  see  the  upper  and  lower  margins 
of  the  disc  and  the  horizontal  vessels  well  defined,  while  the 
lateral  margins  and  the  vertical  vessels  are  blurred,  or  vice  versa, 
Again,  we  know  that  astigmatism  is  present,  if,  in  comparing 
the  shape  of  the  optic  disc  in  the  upright  and  inverted  images, 
we  find  it  to  be  an  oval  with  its  long  axis  perpendicular  in  the 
former,  and  with  its  long  axis  horizontal  in  the  latter,  showing 
that  the  refracting  media  are  more  powerful  in  the  vertical  than 
in  the  horizontal  meridian. 

We  may  ascertain  the  kind  and  degree  of  astigmatism  as 
follows  :  If,  in  the  upright  image  with  relaxed  accommodation, 
we  can  see  the  retinal  vessels  in  one  meridian  distinctly,  while 
in  order  to  see  those  in  the  opposite  meridian  a  concave  or  con- 
vex lens  behind  the  ophthalmoscope  is  required,  we  know  that 
the  case  is  one  of  simple  myopic  or  hypermetropic  astigmatism  ; 
the  emmetropic  meridian  being  that  at  right  angles  to  the  ves- 
sels *  seen  without  any  lens,  and  the  number  of  the  lens  indica- 
ting the  amount  of  ametropia  in  the  other  meridian. 

If,  in  the  two  principal  meridians,  two  concave  lenses  or  two 
convex  lenses  of  different  strength  be  required,  we  have  to  deal 
with  a  case  of  compound  astigmatism,  myopic  or  hypermetropic  ; 
the  greatest  error  of  refraction  being  in  the  meridian  at  right 
angles  to  that  one,  the  vessels  of  which  are  made  distinct  by  the 
strongest  lens. 

If  a  concave  lens  be  required  to  bring  into  distinct  view  the 
vessels  in  one  meridian,  while  a  convex  lens  is  required  for   the 

*  The  vessels  may  be  regarded  as  lines,  and  the  explanation  given  on 
pp.  42  and  43  applies  to  them  also. 


68  DISEASES   OF   THE   EYE. 

opposite  meridian,  the  case  is  one  of  mixed  astigmatism. 
Myopia  exists  in  the  meridian  at  right  angles  to  that  in  which 
the  vessels  are  brought  into  view  by  the  concave  lens,  and  hyper- 
metropia  exists  in  the  opposite  meridian. 

I  would  again  impress  upon  the  reader  the  absolute  necessity 
of  thoroughly  relaxing  his  accommodation  in  all  examinations 
in  the  upright  image.  Paralysis  of  the  patient's  accommodation 
with  atropine  is  necessary  in  most  cases,  where  accuracy  in  the 
determination  of  the  refraction  with  the  ophthalmoscope  is  re- 
quired, and  can  hardly  be  done  without  in  cases  of  hypermetropia 
and  of  hypermetropic  astigmatism,  owing  to  the  cramp  of  ac- 
commodation which  is  almost  always  present. 

Ketinoscopy. 

Another  and  very  useful  method  for  determining  the  refrac- 
tion by  the  ophthalmoscope  is  termed  The  Shadow  Test,  or  Re- 
tinoscopy.  The  appearances  upon  which  this  method  depends 
are  due  to  the  play  of  light  reflected  from  the  mirror  on  the 
fundus  oculi.  Either  a  concave  or  a  plane  ophthalmoscopic 
mirror  may  be  employed.  I  invariably  use  a  plane  mirror ;  but, 
as  I  believe  the  majority  of  ophthalmologists  still  use  the  con- 
cave mirror  in  retinoscopy,  I  shall  describe  the  theory  and  use 
of  the  method  by  its  aid,  and  then  that  by  aid  of  the  plane 
mirror  will  be  readily  understood. 

If  the  rays  from  a  light  (i.  Fig.  46)  be  reflected  from  The 
Concave  Mirror  (m)  of  an  ophthalmoscope,  they  cross  at  a  cer- 
tain point  (A)  and  form  there  an  inverted  image  of  the  flame, 
and  then  diverge  again.  If  these  diverging  rays  be  made  to 
pass  through  a  convex  lens  {B)  placed  at  such  a  distance  in 
front  of  a  screen  {E)  that  the  rays  meet  at  a  focus  on  the  latter, 
a  very  small  and  brilliant  upright  image  (0)  of  the  flame  is 
there  formed,  surrounded  by  a  deep  shadow.  If  the  screen  be 
moved  slightly  toward  the  lens  (to  H),  so  that  the  focus  of  the 
rays  would  lie  behind  it,  or,  if  it  be  removed  slightly  away  from 
the  lens  (to  M),  so  that  the  focus  come  to  lie  in  front  of  it,  the 
brilliancy  of  the  image  on  the  screen  and  the  intensity  of  the 


RETINOSCOPY.  69 

surrounding  shadow  are  reduced.  Because,  in  each  instance,  a 
circle  of  diffusion,  and  not  an  accurate  image,  is  formed  on  the 
screen,  and  the  further  the  focus  of  the  pencil  of  rays  is  situated 
from  the  screen  in  either  direction,  the  weaker  does  the  image 
become,  and  the  more  ill-defined  the  shadow. 

Fig.  46. 


If  the  mirror  be  rotated  in  various  directions,  the  illuminated 
part  *  and  the  shadow  are  seen — care  being  taken  to  look  at  the 
screen  directly,  and  not  through  the  lens — to  move  on  the  screen 

*  "  The  area  of  light,"  "  the  image,"  "  the  illuminated  area,  or  part" 
of  the  fundus,  and  "the  illumination,"  are  different  terms  for  one  and 
the  same  thing.  "  The  shadow  "  or  "  shade  "  refers  merely  to  the  mar- 
gin of  the  illuminated  area,  i.e.^  where  the  illumination  ceases  and  dark- 
ness begins ;  it  does  not  mean  that  the  shadow  of  any  object  is 
thrown  on  the  fundus  oculi.  When  we  speak  of  the  motion  of  the 
shadow,  we  mean  that  the  margin  of  the  illuminated  area,  or  boundary- 
line  between  illuminated  and  non-illuminated  area,  moves  along  with  the 
illuminated  area  in  response  to  the  motion  of  the  mirror.  It  is  easier  to 
learn  how  the  illuminated  area  moves  by  watching  the  margin  of  the 
shadow  (which  comes  across  the  pupil  from  behind  the  iris  like  a  revolv- 
ing shutter  across  a  shop  window),  and  hence  we  have  come  to  talk 
always  of  the  motion  of  the  shadow,  and  not  of  the  motion  of  the 
illuminated  part. 


70 


DISEASES   OF   THE    EYE. 


in  the  opposite  direction  to  the  motion  of  the  mirror.  For  ex- 
ample, if  the  position  m  (Fig,  46)  be  given  to  the  mirror,  the 
path  of  the  rays  reflected  from  it  is  shown  by  the  dotted  lines, 
and  the  image  of  0  is  moved  to  0'.  This  will  also  be  the  case 
if  the  screen  be  at  H  or  at  M.  These  three  positions  of  the 
screen  may  be  supposed  to  represent  emmetropia  (E),  hyperme- 
tropia  (H),  and  myopia  (M).  Fig.  46  more  particularly  illus- 
trates the  motion  of  the  light  and  shade  in  ^  and  ^only,  while 
Fig.  47  demonstrates  that  of  M. 

Fig.  47. 


In  the  eye,  in  like  manner,  the  area  of  light  and  shade  in  the 
pupil  moves  against  the  motion  of  the  mirror.  Now,  we  cannot, 
of  course,  see  the  real  motion  on  the  retina  directly,  but  only 
through  the  dioptric  media,  and  they  will  influence  the  apparent 
motion  according  to  the  condition  of  the  refraction. 

In  emmetropia  and  in  hypermetropia  the  rays  coming  out  of 
the  observed  eye  are  parallel  and  divergent,  respectively;  and, 
consequently,  an  upright  image  being  formed  by  them  in  the 
observer's  eye,  the  true  motion  given  by  the  mirror  is  perceived. 

In  myopia,  at  least  in  all  cases  of  more  than  1  D,  the  observer 
does  not  see  an  upright  image  of  the  flame  on  the  fundus  of  the 


RETINOSCOPY.  71 

observed  eye,  but  a  real  inverted  aerial  image  formed  between 
his  mirror  and  the  observed  eye.  The  reason  of  this  is,  that  the 
rays  coming  out  of  the  patient's  eye  are  convergent,  and  meet 
at  a  focus,  which  is  the  far  point  of  the  eye,  and  form  there  an 
inverted  image  of  the  object  from  which  they  come,  and  which, 
in  this  instance,  is  an  upright  image  of  the  flame  (the  illumin- 
ated area).  When,  therefore,  the  upright  image  on  the  fundus 
moves  against  the  mirror,  the  inverted  image  (which  is  what 
the  observer  sees)  moves  in  the  opposite  direction,  i.  e.,  with  the 
mirror.  For  example,  if  in  Fig.  47  we  suppose  a  to  be  the  po- 
sition of  the  image  on  the  fundus  of  a  myopic  eye,  and  cr  the 
position  of  its  real  inverted  aerial  image,  a  motion  of  the  mirror 
to  m  (the  rays  reflected  from  m  are  omitted,  in  order  to  avoid 
confusion  in  the  diagram)  throws  the  image  of  a  to  a\  as  already 
explained,  but  the  inverted  aerial  image  of  a'  is  formed  at  a" ; 
i.  e.,  it  seems  to  have  moved  with  the  mirror. 

In  myopia  alone,  then,  does  the  image  move  with  the  mirror  ; 
while  in  emmetropia  and  hypermetropia  it  moves  against  the 
mirror.  In  low  myopia  (1  D  and  less),  as  will  just  now  be  seeu, 
the  image  also  moves  ao^ainst  the  mirror. 

From  what  has  been  said,  it  is  evident  that  the  higher  the 
ametropia  (the  further  from  the  screen,  in  Fig.  46,  the  focus  of 
the  rays)  the  larger  and  feebler  the  illumination  becomes  (i.e., 
the  greater  the  circles  of  difiusion),  and  the  more  crescentic  the 
margin  of  the  shadow,  because  it  is  the  margin  of  a  circle  of 
diff'usion. 

Again,  the  extent  of  the  motion  of  the  image  and  its  rate  are 
in  inverse  proportion  to  the  degree  of  the  ametropia.  Thus,  if 
Fig,  48  represent  a  myopic  eye,  whose  far  point  is  situated  at  cr, 
a  motion  of  the  mirror  to  m'  may  be  supposed  to  throw  the 
illuminated  part  to  a,  and  then  cr  will  move  to  cr.  But,  if  the 
myopia  be  of  less  degree,  so  that  the  far  point  is  at  a^,  the  same 
motion  of  the  mirror  will  throw  a^  to  a^,  and  the  distance  be- 
tween these  two  latter  points  is  evidently  much  greater  than  that 
between  a-  and  a-'.  In  a  hypermetropic  eye  (Fig.  49)  the  image 
may  be  supposed  to  be  formed  at  a,  and  a  motion  of  the  mirror 


72  DISEASES   OF   THE   EYE. 

to  m'  will  throw  it  to  a' ;  while  in  a  higher  degree  of  hyperme- 
tropia  it  would  be  formed  at  h,  and  the  same  motion  of  the  mir- 
ror would  throw  it  to  h'.  The  distance  between  b  and  h'  is  much 
greater  than  that  between  a  and  a'. 

In  practicing  retinoscopy  with  the  concave  mirror  the  surgeon 

Fig.  48. 


sits  1.20  m.  in  front  of  the  patient.  The  eye  to  be  examined  is 
shaded  from  the  direct  rays  of  the  lamp,  if  the  latter  be  placed 
beside  the  patient;  but  a  better  plan  is  to  have  the  light  above 
his  head.     The  focus  of  the  mirror  should  be  22  cm.,  and  any 


Fig.  49. 


error  of  refraction  of  the  surgeon  is  to  be  corrected.  The  light 
is  thrown  into  the  eye  at  an  angle  of  about  15°  with  its  axis  of 
vision,  so  that,  if  the  pupil  be  not  under  the  influence  of  atro- 
pine, the  macula  lutea  may  be  avoided.  In  children,  and  when 
the  pupil  is  very  small,  it  is  advisable  to  dilate  it  with  atropine, 


RETIXOSCOPY.  73 

and  then  the  region  of  the  macula  lutea  may  be  utilized.  When 
now  the  ophthalmoscope  is  rotated  in  different  directions,  motions 
of  the  light  and  shade  on  the  fundus  oculi  are  seen  in  the  pupil- 
lary area.  The  surgeon  directs  his  attention  to  the  edge  of  the 
shadotv  rather  than  to  the  illuminated  part,  for  its  motion  is 
more  easily  appreciated.  If  the  edge  of  the  shadow  move  with 
the  motion  of  the  mirror,  myopia  is  present ;  if  it  move  against 
the  mirror,  emmetropia,  hypermetropia,  or  myopia  of  1  D  or 
less  is  present. 

The  reason  why  the  motion  is  against  the  mirror  in  cases 
of  M.  1  D  and  less  is,  that  the  surgeon  being  seated  only  1.20  m. 
from  the  eye  he  is  examining,  if  that  eye  have  a  myopia  of  1  D, 
its  far  point  is  so  close  to  his  eye  that  he  cannot  clearly  observe 
the  image  there  formed  ;  but,  if  the  myopia  be  of  even  slighter 
degree,  the  image  will  be  formed  behind  the  surgeon's  head,  and 
he  gets  a  shadow  moving  against  the  motion  of  his  mirror,  be- 
cause the  image  he  then  sees  is  the  upright  one  on  the  patient's 
fundus  oculi,  and  not  the  inverted  aerial  image. 

We  proceed  as  follows  :  A  trial  spectacle-frame  is  put  on  the 
patient's  face.  If  the  shadow  move  with  the  mirror,  we  know  at 
once  the  eye  is  myopic.  To  find  the  degree  of  myopia,  the  sur- 
geon puts  a  low  concave-glass,  say  —  ID,  into  the  frame  ;  and, 
if  the  shadow  still  move  with  the  mirror,  he  puts  in  a  higher 
number,  say  — 1.5  D,  and  so  on,  until  he  comes  to  a  glass  which 
makes  the  image  move  against  the  mirror.  If  this  be  —  3D,  the 
myopia  is  3  D.  It  might  be  supposed,  as  the  shadow  now  moves 
against  the  mirror,  that  this  glass  over-corrects  the  myopia,  but 
this  is  not  so  ;  because,  as  already  explained,  when  the  myopia 
is  very  low,  the  image  is  formed  close  to  the  surgeon's  eye,  or 
behind  his  head,  and  he  consequently  gets  a  shadow  moving 
against  the  mirror,  although  low  myopia,  and  not  emmetropia,  is 
present.  Consequently,  —  0.5  D  or  —  ID  has  to  be  added  on  to 
the  lens,  which  gives  the  effect  of  no  distinct  shadow ;  or  rather, 
by  the  above  plan,  it  is  not  deducted  from  the  lowest  lens,  which 
makes  the  shadow  move  against  the  mirror. 

If  the  shadow  move  against  the  mirror,  we  have  to  determine 
7 


74  DISEASES   OF   THE    EYE. 

whether  the  eye  be  emmetropic,  hypermetropic,  or  slightly  my- 
opic. Should  the  illumination  be  bright  and  the  shadow  well 
defined,  the  eye  is  emmetropic,  or  not  far  removed  from  it ;  and 
if  the  shadow  be  ill  defined  and  crescentic  we  may  feel  sure  the 
eye  is  highly  hypermetropic.  We  first  put  on  +  1  D,  and  if 
the  motion  be  still  against  the  mirror  the  case  is  one  of  hyper- 
metropia,  and  higher  numbers  are  at  once  proceeded  with,  until 
that  one  is  reached  which  causes  the  shadow  to  move  with  the 
mirror.  The  measure  of  the  hypermetropia  is  1  D  less  than  the 
glass  so  found,  for  it  has  evidently  over-corrected  the  defect. 

If,  however,  on  putting  on  -j-  1  D  we  find  the  shadow  to 
move  with  the  mirror,  we  change  it  for  -|-  0.5  D ;  and,  if  still 
the  motion  be  with  the  mirror,  the  eye  is,  beyond  doubt,  slightly 
myopic,  —  0.5  D  or  so.  But  if  with  -f-  1  D  the  shadow  move 
with  the  mirror,  while  with  -f  0.5  it  continue  to  move  against 
it,  the  eye  is  emmetropic. 

It  may  be  found  that  in  two  opposite  meridians  there  is  a 
difi^erence  in  the  motion  of  the  shadow,  and  this  leads  us  to 
diagnose  the  presence  of  astigmatism.  When  the  difference  is 
one  merely  of  rapidity  of  motion  or  of  intensity  of  illumination 
and  shadow,  we  know  that  we  have  to  deal  with  either  simple 
or  compound  astigmatism.  But  if,  in  the  two  meridians,  there 
be  a  difference  in  the  direction  of  the  motion,  then  it  is  a  case 
of  mixed  astigmatism.  The  best  method  for  ascertaining  the 
degree  of  astigmatism  and  its  correcting  glass  is  to  correct  each 
of  the  principal  meridians  separately  with  spherical  lenses.  In 
compound  astigmatism,  the  diflference  between  the  two  lenses 
found  indicates  the  degree  of  astigmatism,  and  also  the  cylindri- 
cal lens  which,  combined  with  the  correcting  spherical  lens  for 
the  least  ametropic  meridian,  is  required  to  neutralize  the  defect. 
In  mixed  astigmatism  the  addition  of  the  two  numbers  gives  the 
cylindrical  lens,  while  one  or  other  of  them,  usually  the  +  Dj  is 
used  as  the  spherical  lens. 

With  Tlie  Plane  Mirror  the  source  of  illumination  of  the 
observed  eye  is  not  a  real  inverted  image  of  the  light,  as  in 
the  case  of  the  concave  mirror,  but  a  virtual  upright  image 


RETINOSCOPY.  75 

behind  the  mirror ;  and,  as  this  image  moves  in  the  opposite 
direction  to  the  motion  of  the  mirror,  the  motion  of  its  illu- 
mination on  the  fundus  of  the  patient's  eye  must  be  uiih  the 
mirror  in  all  cases,  and  not  against  it,  as  in  using  the  concave 
mirror. 

With  the  plane  mirror,  therefore,  the  shadow  is  seen  to  move 
ivith  the  motion  of  the  mirror  in  H.  and  E.  But  in  M.  it  seems 
to  move  against  the  motion  of  the  mirror,  for  what  we  here  see 
is  an  inverted' image  of  the  fundus  situated  at  the  far  point  of 
the  eye.  If  the  myopia  be  high,  this  inverted  image  will  be 
close  to  the  eye;  if  low,  it  will  be  far  away  from  it.  In  using 
the  plane  mirror  it  is  important  to  remember  this  point,  because, 
if  the  observer  go  nearer  to  a  myopic  eye  than  its  far  point,  he 
will  not  obtain  a  myopic  motion,  but  one  which  is  the  same  as 
that  in  E.  or  H.  Consequently,  in  using  the  plane  mirror,  the 
rule  is  to  go  as  far  from  the  eye  under  examination  as  possible. 
If,  at  the  beginning,  the  surgeon  retire  a  little  more  than  two 
metres  from  the  eye,  and  there  obtain  a  with-motion,  he  at  once 
knows  that  the  eye  is  not  myopic  0.5  D ;  or,  if  he  stand  a  little 
more  than  four  metres  away,  and  obtain  the  same  motion,  he  knows 
there  is  not  a  myopia  of  even  0.25  D  present.  If  the  myopia  be 
high,  he  will  be  able  to  begin  close  to  the  patient,  but  must 
gradually  retire  from  the  eye  as  he  increases  the  number  of  the 
concave  glass  put  up — for  the  far  point  is  thereby  moved  further 
off— in  order  that  he  may  not  think  he  has  corrected  the  myopia 
before  he  really  has  done  so.  Again,  if  at  every  distance  the 
motion  be  with  the  mirror,  the  surgeon  has  to  decide  whether 
this  indicate  E.  or  H.  He  does  this  by  putting  a  low  lens,  say 
+  0.25,  before  the  patient's  eye,  and  if  then,  standing  at  a  dis- 
tance of  four  metres,  the  motion  be  altered  by  this  glass  to  one 
against  the  mirror,  he  knows  that  the  eye  has  not  a  hyperme- 
tropia  of  0.25  D,  consequently  that  it  is  emmetropic ;  but  if  this 
lens  do  not  at  that  distance  cause  a  change  in  the  motion  of  the 
shadow  as  originally  obtained,  the  eye  must  be  hypermetropic  to 
at  least  the  extent  of  0.25  D  ;    and,  in  order  to  ascertain  how 


76  DISEASES   OF   THE   EYE. 

much  more  of  H.  than  this  may  be  present,  it  is  now  only  neces- 
sary to  go  on  increasing  the  strength  of  the  lens  in  front  of  the 
patient's  eye,  until  one  is  reached  which,  at  four  metres  from  the 
eye,  produces  the  myopic  motion.  The  observer  knows  that  he 
has  now  slightly  over-corrected  the  hypermetropia  of  the  eye, 
and  that  the  next  lens  lower  is  its  measure. 

With  some  practice  it  is  possible,  unless  the  pupil  be  small,  to 
obtain  sufficient  light  from  the  fundus  with  the  plane  mirror  at 
a  distance  of  four  metres. 

I  find  this  method  much  more  easily  worked  than  that  with 
the  concave  mirror.  It  has  the  advantage,  too,  of  not  requir- 
ing any  wearisome  addition  to  or  subtraction  from  the  data 
obtained. 

The  pleasantest  plane  mirror  is  one  of  4  cm.  diameter,  and  of 
which  the  sight-hole  is  4  mm.  in  diameter. 


FOCAL    OR    OBLIQUE    ILLUMINATION 

is  employed  for  the  examination  of  the  cornea,  iris,  and  lens. 
With  a  high  -\~  lens  (16  to  18  D)  the  light  of  the  gas  flame  is 
concentrated  on  the  part  to  be  examined  with  an  oblique,  not  a 
perpendicular,  incidence  of  the  concentrated  rays.  Small  foreign 
bodies  in  the  iris,  cornea,  or  lens,  or  opacities  in  either  of  the 
latter,  can  be  thus  detected.  Extremely  delicate  opacities  in 
the  cornea  are  not  seen  best  with  the  strongest  illumination 
which  can  in  this  way  be  produced ;  but,  rather,  by  the  half- 
light  which  is  obtainable  at  the  edge  of  the  cone  of  light  pass- 
ing from  the  lens.  In  examining  the  centre  of  the  crystalline 
lens,  the  incidence  of  the  light  must  necessarily  be  more  per- 
pendicular. 


THE  NORMAL  FUNDUS  OCULI.  77 

THE  NORMAL  FUNDUS  OCULI  AS  SEEN  WITH 
THE    OPHTHALMOSCOPE. 

RefereDce  has  been  made  to  the  enlargement  of  the  image  of 
the  fundus  oculi  seen  with  the  ophthalmoscope.  The  cause  of 
this  enlargement  is,  that  the  fundus  is  observed  through  a  diop- 
tric system,  at,  or  close  to,  the  principal  focus  of  which  it  is 
situated,  and  which,  consequently,  magnifies  it  to  our  view.  The 
enlargement  of  the  inverted  image  is  not  so  great  as  that  of  the 
upright  image,  and  it  is  smaller  the  shorter  the  focal  length  of 
the  convex  lens  employed.  The  inverted  image  of  a  hyperme- 
tropic eye  is  larger  than  that  of  an  emmetropic  eye,  and 
the  latter  larger  than  that  of  a  myopic  eye.  It  is  possible 
to  determine  mathematically  the  degree  of  enlargement  of  the 
image. 

The  Optic  Papilla. — This  is  the  first  object  to  be  sought  for  by 
the  observer.  It  presents  the  appearance  of  a  pale  pink  disc, 
somewhat  oval  in  shape,  its  long  axis  being  vertical.  Occasion- 
ally the  long  axis  lies  horizontally,  and  sometimes  the  papilla  is 
circular.  The  papilla  is  generally  surrounded  by  a  white  ring, 
more  or  less  complete,  called  the  sclerotic  ring,  and  often,  outside 
this  again,  by  a  more  or  less  complete  black  line,  the  choroidal 
ring.  The  sclerotic  ring  is  due  to  the  choroidal  margin  not 
coming  quite  up  to  the  margin  of  the  papilla,  the  foramen  in 
the  choroid  for  the  passage  of  the  optic  nerve  fibres  being  some- 
what larger  than  that  in  the  sclerotic,  and,  consequently,  a 
narrow  edging  of  the  white  sclerotic  is  exposed.  The  choroidal 
ring  is  the  result  of  a  hyper-development  of  pigment  at  the 
margin  of  the  choroidal  foramen.  The  complexion  of  the  optic 
papilla  results  from  the  pink  hue  derived  from  its  fine  capillary 
vessels,  combined  with  the  whiteness  of  the  lamina  cribrosa  and 
the  bluish  shade  of  the  nerve  fibres.  It  is  frequently  not  equal 
all  over,  but  is  paler  on  the  outer  side,  where  the  nerve  fibres 
are  often  fewer  than  on  the  inner  side.  The  apparent  color  of 
the  papilla  depends,  also,  upon  the  complexion  of  the  rest  of  the 
fundus.     If  the  latter  be  highly  pigmented,  the  papilla  appears 


78  DISEASES   OF   THE    EYE. 

pale  in  contrast ;  while,  if  there  be  but  little  pigment  in  the 
choroid,  the  papilla  may  appear  very  pink.  The  complexion  of 
every  normal  papilla  is  not  identical,  and  care  must  be  taken 
not  to  make  the  diagnosis  "Hyperemia  of  the  papilla,"  where 
merely  a  high  physiological  complexion  is  present. 

A  physiological  excavation  of  the  optic  papilla  is  often  met 
with.  It  is  always  on  the  temporal  side  of  the  papilla,  and  can 
be  recognized  from  the  parallax  *  which  may  be  produced,  and 
from  the  paleness  of  this  portion  of  the  papilla.  When  the  exca- 
vation is  very  deep,  one  may  sometimes  observe  the  lamina 
cribrosa  in  the  form  of  gray  spots  (the  nerve  fibres),  surrounded 
by  white  lines  (the  fibrous  tissue  of  the  lamina). 

A  physiological  differs  ophthalmoscopically  from  a  pathological 
excavation,  by  the  fact  that  it  does  not  reach  the  margin  of  the 
papilla  all  round.  It  is  caused  by  the  crowding  over  of  the 
nerve  fibres  to  the  inner  side  of  the  papilla.  Yet  sometimes  a 
healthy  optic  papilla  will  be  met  with,  in  which  the  excavation 
apparently  reaches  the  margin  all  round.  Doubtless,  in  such 
cases,  the  thickness  of  the  translucent  nerve-fibre  layer  alone  it  is 
which  is  interposed  between  the  sclerotic  margin  and  the  margin 
of  the  cup  all  round. 

The  Normal  Retina  is  so  translucent  that  it  cannot  be  seen  ; 
or,  at  most,  a  shimmering  reflection,  or  shot-silk  appearance,  is 
obtained  from  it,  particularly  about  the  region  of  the  yellow 
spot  and  along  the  vessels,  but  also  toward  the  equator  of  the 
eye,  and  especially  in  dark  eyes  and  in  young  people. 

A  peculiar,  but  physiological,  appearance,  known  as  "  opaque 
nerve  fibres,"  is  occasionally  seen.  It  is  produced  by  some  of 
the  nerve  fibres  forming  the  internal  layer  of  the  retina  regain- 
ing the  medullary  sheath  on  the  distal  aspect  of  the  lamina 
cribrosa,  or  near  the  margin  of  the  papilla,  which  they  had  lost 
in  the  optic  nerve  just  before  entering  the  lamina  cribrosa;  the 
rule  being  that  the  nerve  fibres  lose  their  medullary  sheath  at 
the  latter  place  definitely,  and  enter  the  retina  as  axis  cylinders 

*  For  explanation  of  the  parallax  see  Chap.  XII. 


THE  NORMAL  FUNDUS  OCULI.  79 

only,  and  hence  are  quite  translucent.  Instead  of  that,  in  these 
cases  their  fibres  reflect  the  light  strongly,  giving  the  efl?ect  of  an 
intensely  white  spot,  commencing  at  the  papilla,  extending  more 
or  less  into  the  surrounding  retina,  and  terminating  in  a  brush- 
like extremity.  This  appearance  is  constant  in  the  rabbit's 
eye. 

The  Macula  Lutea  is  generally  seen  as  a  bright  oval  ring  with 
its  long  axis  horizontal,  this  ring  being  probably  a  reflex  from 
the  surface  of  the  retina.  It  is  remarkable  that  this  halo  is  not 
visible  with  the  direct  method  of  examination — a  fact  due,  prob- 
ably, to  the  illumination  being  much  weaker  than  with  the 
indirect  method.  The  area  inside  the  ring  is  of  a  deeper  red 
than  the  rest  of  the  fundus,  and  at  its  very  centre  there  is  an 
intensely  red  point,  the  fovea  centralis. 

The  General  Fundus  Oculi  surrounding  the  optic  papilla  and 
macula  lutea  varies  a  good  deal  in  appearance,  according  to  the 
amount  of  pigment  contained  in  the  choroid  and  in  the  pigment- 
epithelium  layer  of  the  retina.  1.  If  there  be  an  abundant  sup- 
ply of  pigment  in  each  of  these  positions,  the  choroidal  vessels 
are  greatly  hidden  from  view,  and  the  effect  is  that  of  a  very 
dark  red  fundus.  2.  If  there  he  but  little  pigment  in  the  pig- 
ment-epithelium layer,  the  larger  choroidal  vessels  may  be 
visible,  and  the  fundus  may  appear  to  be  divided  up  into  dark 
islands  surrounded  by  red  lines.  3.  If  the  individual  be  a 
blonde,  there  is  little  pigment  either  in  the  pigment-epithelium 
layer  or  in  the  choroid,  and  the  fundus  is  seen  of  a  very  bright 
red  color,  the  choroidal  vessels  down  to  their  fine  ramifications 
being  discernible.  In  albinos  even  the  choroidal  capillaries 
may  be  seen. 

The  Retinal  Vessels. — The  arteries  are  recognized  as  thin, 
bright  red  lines  running  a  rather  straight  course,  in  the  centre 
of  each  of  which  is  a  light-streak  due  to  reflection  from  the 
tense  coat  of  the  vessel.  This  light-streak  divides  the  vessel 
into  two  red  lines.  The  veins  are  darker,  wider,  and  more 
tortuous  in  their  course  than  the  arteries,  and,  their  coats  not  being 
so  tense,  the  light-streak  is  very  much  fainter. 


80 


DISEASES   OF   THE    EYE. 


On  reaching  the  level  of  the  nerve-fibre  layer  of  the  retina, 
the  central  artery  and  vein  divide  into  a  principal  upper  and 
lower  branch.  This  first  branching  often  takes  place  earlier  in 
the  vein  than  in  the  artery,  and  the  former  may  even  branch  before 
appearing  on  the  papilla,  as  in  Fig.  50.  The  second  branching 
may  take  place  in  the  nerve  itself;  and,  when  this  occurs,  it  will 

Fig.  50. 


I.  n.  s  ,  Art.  nas.  sup.;  a.n.i.,  Art.  nas.  inf.;  a.t.s.,  a.i.i.,  A.  temp.  sup.  and  inf., 
v.n.s.,  v.n.i..  Ven  nas.  sup.  and  inf.;  i- «. «.,  t;. <.i.,  Ven.  temp. sup.  and  inf. ;  a.m.c, 
v.m.e.,  Art.  and  ven.  median;  aw.,  v.m.,  Art.  and  ven.  macularis.— (<?)fle/e  and 
Scemisch). 


appear  as  though  four  arteries  and  four  veins  sprang  from  the 
optic  papilla ;  but,  more  usually,  this  branching  occurs  on  the 
papilla,  as  in  Fig.  50.  The  vessels  produced  by  this  second 
branching  pass  respectively  toward  the  median  and  temporal 
^ide  of  the  retina,  and  are  termed  by  INIagnus  the  Art.  and  Ven. 


THE    NORMAL    FUNDUS    OCULI.  81 

Dasalis  aod  temporalis  sup.  and  inf.  (^vide  Fig.  50).  The  tem- 
poral branches  run  in  a  radial  direction  toward  the  anterior 
part  of  the  retina.  A  small  horizontal  branch,  the  Art.  and 
Ven.  mediana  of  Magnus,  from  the  first  principal  branches,  is 
found  passing  toward  the  nasal  side  of  the  retina.  The 
temporal  branches  do  not  run  in  a  horizontal  direction,  but 
make  a  detour  round  the  macula  lutea,  sending  fine  branches 
toward  the  latter.  Two  or  three  minute  vessels  from  principal 
branches  run  directly  from  the  papilla  toward  the  macula 
lutea ;  and  around  the  macula  lutea  a  circle  of  very  fine  capillary 
vessels  is  formed,  which  cannot  be  distinguished  with  the  ophthal- 
moscope ;  but  no  vessels  run  to,  or  cross  over,  the  fovea  centralis 
itself.  The  retinal  arteries  do  not  anastomose,  nor  do  the  larger 
retinal  veins.  The  small  retinal  veins  have  some  slight  anasto- 
moses near  the  ora  serrata. 

No  pulsation  of  the  arteries  is  observable  in  the  normal  eye. 
In  the  larger  veins  near  or  on  the  optic  papilla,  or,  more  usually, 
just  at  their  point  of  exit,  a  pulsation  may  sometimes  be  seen. 
This  venous  pulsation  is  due  to  the  following  sequence  of 
events:  Systole  of  the  heart;  diastole  of,  and  high  tension  in, 
the  retinal  arteries;  consequent  increased  pressure  in  the 
vitreous  humor;  communication  of  this  to  the  outside  of  the 
walls  of  the  retinal  veins,  impeding  the  flow  of  blood  through 
them,  especially  in  their  larger  trunks,  which  oflTer  little  resis- 
tance, or  at  their  exit  from  the  eye,  where  they  ofl^er  the  least 
resistance  ;  and  in  this  way  the  veins  are  emptied  :  the  blood 
gradually  coming  on  from  the  capillaries  overcomes  the  resist- 
ance, and  the  veins  are  for  a  moment  refilled.  The  phenomenon 
can  be  most  readily  observed  if  the  normal  tension  of  the  globe 
be  slightly  increased  by  pressure  of  a  finger. 


CHAPTER  IV. 

DISEASES  OP  THE   CONJUNCTIVA. 

Hyperaemia  of  the  Conjunctiva. — In  this  condition  the  blood- 
vessels of  the  palpebral  conjunctiva  especially  are  engaged. 
Slight  chemosis  sometimes  appears,  small  vesicles  may  form,  and 
there  may  also  be  some  swelling  of  the  papillae  and  develop- 
ment of  lymph  follicles.  There  is  not  any  abnormal  discharge 
from  the  conjunctiva,  and  herein  lies  the  chief  point  of  difference 
between  this  affection  and  simple  conjunctivitis. 

Causes. — Foreign  bodies.  Foul  air,  or  air  loaded  with  tobacco- 
smoke.  Alcoholic  excesses.  Accommodative  asthenopia.  Steno- 
sis lachrymalis,  and  other  forms  of  lachrymal  obstruction.  The 
ues  of  unsuitable  spectacles,  or  the  use  of  the  eyes  for  near  work 
without  spectacles  when  the  condition  of  the  accommodation 
{e.g.,  hypermetropia,  presbyopia)  requires  them. 

Symptoms. — The  eyes  are  irritable.  There  is  lachrymation  and 
photophobia,  with  hot,  burning  sensations,  and  sensations  as  of  a 
foreign  body  in  the  eye,  and  the  eyelids  feel  heavy.  All  these 
symptoms  are  aggravated  in  artificial  light. 

Treatment. — In  addition  to  the  removal  of  the  cause,  iced 
compresses  are  to  be  applied  to  the  closed  eyelids  for  twenty 
minutes  several  times  a  day,  and  the  instillation  of  a  drop  of 
tincture  of  opium  and  distilled  water  in  equal  parts  morning  and 
evening  will  be  found  beneficial.  It  is  also  desirable  to  wash  out 
the  lachrymal  passages  with  an  Anel's  syringe,  even  where  no 
decided  lachrymal  obstruction  is  present. 

The  eyes  should  be  protected  from  glare  of  light  by  dark 
glasses,  and  out-of-door  exercise  is  to  be  recommended. 

Conjunctivitis  in  general. — In  addition  to  hyperaemia,  there  is 
here  abnormal  secretion.     There  are  several  forms  of  conjunc- 

82 


THE   CONJUNCTIVA.  83 

tivitis,  the  discharge  from  each  being  more  or  less  contagious. 
The  secretion  from  any  given  form  will  not,  however,  always  re- 
produce that  form,  but  may  give  rise  to  another  of  greater  or  less 
severity.  Infection  takes  place  by  the  direct  application  of  the 
secretion,  or  also — it  is  very  generally  thought — through  the  air, 
in  which  float  particles  of  the  infecting  substance.  This  latter 
mode  is  especially  liable  to  exist,  it  is  said,  in  an  ill-ventilated 
room,  where  a  number  of  people  affected  with  conjunctival 
diseases  are  lodged  with  others  who  possess  healthy  eyes,  e.g.,  in 
crowded  charity-schools.  The  palpebral  conjunctiva  is  often 
affected  when  the  bulbar  portion  remains  normal,  and  the  con- 
junctiva of  the  lower  lid  is  more  frequently  attacked  than  that  of 
the  upper  lid. 

Catarrhal,  or  Simple  Acute,  Conjunctivitis. — In  mild  cases 
the  affection  is  confined  to  the  palpebral  conjunctiva,  often  even 
to  the  conjunctiva  of  the  lower  lid ;  but  in  the  severer  cases  it 
extends  to  the  bulbar  conjunctiva.  Lymph  follicles  and  enlarged 
papillae  are  frequently  present,  but  not  necessarily  so.  There  is 
a  sticky,  serous  secretion,  which  causes  the  eyelids  to  be  fastened 
together  on  awaking  in  the  morning,  and  sometimes  produces 
ulceration  of  the  interraarginal  portion  of  the  eyelids  (inter- 
marginal  blepharitis).  In  some  of  the  very  mildest  cases  this 
"stickiness"  or  "gumming"  on  awaking  in  the  morning  is  a 
valuable  diagnostic  sign,  for  it  is,  in  such  cases,  difficult  or  im- 
possible to  recognize  the  very  slight  variation  from  the  healthy 
appearance  of  the  conjunctiva. 

In  the  severer  cases  the  papillae  are  markedly  swollen,  and 
may  even  conceal  the  Meibomian  glands  from  view.  Also  one 
often  sees  small  ecchymoses  in  the  bulbar  conjunctiva,  especially 
in  certain  epidemics.     But  these  have  no  serious  import. 

Minute  gray  infiltrations  sometimes  form  at  the  margin  of  the 
cornea.  When  there  are  many  of  them,  they  may  become  con- 
fluent and  form  a  small  gray  crescent,  which  ulcerates,  and  thus 
a  crescentic  marginal  ulcer  is  formed,  and  very  occasionally  such 
an  ulcer  is  followed  by  iritis. 

The  catarrh  may  become  chronic,  and  then  the  papillae  are 


84  DISEASES   OF   THE   EYE. 

more  developed,  while  the  blepharitis  is  liable  to  extend  over  to 
the  cutis,  causing  eversion  of  the  lower  punctum  lachryraale  with 
resulting  stillicidium,  and  this,  in  its  turn,  aggravates  the  con- 
junctival affection. 

The  Symptoms  are  those  of  a  severe  case  of  hyperieraia  (sensa- 
tions of  sand  in  the  eye,  hot,  burning  sensations,  weight  of  the 
eyelid),  with  the  addition  of  the  annoyance  consequent  on  the 
secretion,  which,  by  coming  across  the  cornea,  may  cause  momen- 
tary clouding  of  sight.  Photophobia  is  not  generally  severe  un- 
less there  be  some  corneal  complication. 

Causes. — Draughts  of  cold  air.  Contagion.  Foul  atmosphere. 
As  an  epidemic.  Foreign  bodies.  As  a  sequel  of,  or  attendant 
on,  scarlatina,  measles,  and  smallpox. 

Diagnosis. — The  presence  of  the  gummy  secretion  distinguishes 
this  affection  from  mere  hypersemia  of  the  conjunctiva.  A  com- 
mon mistake  amongst  those  not  familiar  with  eye  diseases  is  to 
regard  a  case  of  iritis  as  one  of  simple  acute  conjunctivitis,  the 
redness  of  the  white  of  the  eye  in  the  former  affection  being 
taken  for  conjunctival  hyperemia,  etc.;  and,  moreover,  a  slight 
secondary  conjunctivitis  does  undoubtedly  attend  many  cases  of 
iritis. 

The  circumcorneal  subconjunctival  vessels,  derived  from  the 
anterior  ciliary  vessels,  are  those  which  become  engorged  in  iritis, 
and  their  engorgement  gives  rise  to  a  pink  or  pale  violet  zone 
around  the  cornea,  of  which  the  separate  vessels  cannot  be  dis- 
tinctly seen.  The  conjunctival  vessels  may  be  distinguished  from 
the  subconjunctival  or  ciliary  vessels  by  the  possibility  of  mov- 
ing the  former,  along  with  the  membrane  in  which  they  are,  by 
manipulations  which  can  be  made  with  the  lower  lid  of  the  pa- 
tient, while  these  manipulations  do  not  affect  the  ciliary  vessels. 
The  separate  conjunctival  vessels,  too,  can  be  easily  distinguished, 
and  they  are  of  a  bright  red  color.  The  condition  of  the  iris 
itself,  however,  is  that  upon  which  the  diagnosis  finally  depends. 
(See  Iritis,  Chap.  X.) 

The  Prognosis  is  good  if  there  be  no  reason  to  suspect  that  the 
mild  form  is  but  the  commencement  of  a  more  severe  inflamma- 


THE   CONJUNCTIVA.  85 

tion.  The  infiltrations,  and  even  the  ulcers,  which  sometimes 
form  at  the  margin  of  the  cornea,  are  not  often  of  serious  import, 
and  heal  according  as  the  treatment  restores  the  conjunctiva  to 
health. 

Treatment. — Cold  or  iced  compresses,  with  the  use  of  a  4  per 
cent,  solution  of  boracic  acid  as  a  lotion,  should  be  used  fre- 
quently at  the  first  onset,  and,  in  mild  cases,  will  alone  bring 
about  a  cure.  But  the  habit,  which  some  patients  so  readily 
acquire,  of  bathing  the  eyes  frequently  with  cold  water  should 
not  be  permitted,  for  it  is  deleterious  to  the  conjunctival  aflTec- 
tion.  When,  in  a  day  or  two,  the  irritation  and  swelling  have 
somewhat  subsided — or  from  the  very  commencement  if  there  be 
not  much  irritation — a  solution  of  nitrate  of  silver,  of  from  5  to 
10  grains  to  5J,  should  be  applied  by  the  surgeon  to  the  palpe- 
bral conjunctiva  with  a  camel's-hair  pencil,  the  lid  being  well 
everted,  and  this  then  should  be  thoroughly  neutralized  with  salt 
water,  the  whole  being  finally  washed  off  with  plain  water.  The 
application  is  to  be  repeated  in  twenty-four  hours,  by  which  time 
the  slight  loss  of  epithelium,  the  result  of  the  superficial  slough, 
will  have  been  repaired.  Immediately  after  such  an  application 
cold  sponging  or  iced  compresses  are.  useful,  and  grateful  to  the 
patient.  The  greatest  care  is  required  in  the  use  of  nitrate  of 
silver  in  conjunctival  affections  for  any  prolonged  period,  lest  it 
cause  that  brownish  staining  of  the  membrane  called  Argyrosis 
(apyu/yo?j  silver) ;  thorough  neutralization  and  washing,  as  above 
recommended,  being  the  best  safeguards.  I  am  opposed  to  the 
use  even  of  weak  solutions  of  nitrate  of  silver  as  eye-drops  to  be 
used  at  home  by  the  patient,  for  staining  is  very  apt  to  be  caused 
in  this  way. 

Should  the  surgeon  be  unable  to  see  the  patient  daily,  the 
following  simple  eye-drops  are  capable  of  effecting  a  rapid  cure 
in  most  cases  : — R.  Acid.  Boracici,  gr.  v  ;  Zinci  Sulph.,  gr.  ij  ; 
Tinct.  Opii,  sj ;  Aq.  destill.  ad  5J ;  one  drop  in  the  eye  morning 
and  evening,  or  only  once  a  day  in  mild  cases.  Solutions  of 
alum  (gr.  iv  to  f5J  of  water)  and  of  tannic  acid  (gr.  v  to  viij  to 


86  DISEASES   OF   THE    EYE. 

f  3  j  of  water)  are  often  prescribed,  but  are  not  so  effectual  as  the 
foregoing. 

A  weak  boracic  acid  ointment,  to  be  applied  along  the  margins 
of  the  lids  at  bedtime,  is  to  be  ordered.  It  prevents  the  "gum- 
rainess"  in  the  morning,  which  is  not  only  unpleasant  to  the 
patient,  but  is  also  injurious,  by  fastening  the  eyelids  together 
and  thus  preventing  free  drainage  of  the  secretion. 

Follicular  Conjunctivitis. — This  is  catarrhal  conjunctivitis,  to 
which  is  added  the  presence  in  the  conjunctiva  of  small  round, 
pinkish  bodies  the  size  of  a  pin's  head,  which  disappear  com- 
pletely as  the  process  passes  off,  leaving  the  mucous  membrane 
as  healthy  as  they  found  it. 

These  little  bodies  are  situated  chiefly  in  the  lower  fornix  of 
the  conjunctiva,  and  may  be  discovered  by  eversion  of  the  lower 
lid,  when  they  will  be  seen  arranged  in  rows  parallel  to  the 
margin  of  the  lid.  Whether  they  are  easily  discovered  or  not 
depends  on  their  size  and  number,  and  on  the  amount  of  coexist- 
ing hypersemia  or  chemosis  of  the  conjunctiva.  The  structure  of 
these  bodies  shows  them  to  be  lymph  follicles. 

Follicular  conjunctivitis  is  a  very  tedious  form,  lasting  often 
for  months.  According  to  Ssemisch,  it  is  more  apt  to  give  rise 
to  marginal  ulceration  of  the  cornea  than  the  simple  catarrhal 
form  ;  but  I  have  not  myself  observed  this.  I  agree  with  those 
who  hold  that  the  disease  has  nothing  to  do  with  granular 
ophthalmia,  although  some  authors  regard  it  as  an  early  stage  of 
the  latter. 

The  Symptoms  are  much  the  same  as  those  of  catarrhal  con- 
junctivitis. Frequently,  there  is  little  or  no  injection  of  the 
bulbar  conjunctiva,  and  the  chief  symptom  is  asthenopia — an 
inability  to  continue  near  work  for  any  length  of  time — and 
much  distress  in  artificial  light.  Boys  and  girls  from  five  to 
fifteen  years  of  age  are  those  most  liable  to  this  affection. 

Causes. — These  are  also  much  the  same  as  in  simple  catarrhal 
conjunctivitis.  The  long-continued  use  either  of  atropine  or  of 
eserine  is  liable  to  bring  on  the  disease. 


THE    CONJUNCTIVA.  87 

Treatment. — The  remedy  I  have  found  most  useful  in  this 
troublesome  affection  is  an  ointment  of  sulphate  of  copper  from 
gr.  ss.  to  gr.  ij  in  ^]  of  vaseline.  The  weaker  ointments  should 
be  used  at  first,  and  later  on  the  stronger  ones,  if  it  be  found 
that  the  eye  can  bear  them.  The  size  of  half  a  pea  of  the  oint- 
ment is  inserted  into  the  conjunctival  sac  with  a  camel's-hair 
pencil  once  a  day.  Eye-drops  of  equal  parts  of  tincture  of  opium 
and  distilled  water  are  of  use  in  some  cases  ;  and  the  eye-douche 
should  be  recommended.  Abundance  of  fresh  air,  with  change 
from  a  damp  climate  or  neighborhood  to  a  dry  one,  is  of  impor- 
tance. If  the  use  of  a  solution  of  atropine  have  induced  the 
disease,  it  should  be  discontinued ;  and,  if  a  mydriatic  be  still 
required,  a  solution  of  extract  of  belladonna  (gr.  viij  ad  5J)  may 
be  employed  in  its  stead. 

Spring  Catarrh  is  the  eye  complication  which  accompanies  that 
troublesome  affection  known  as  "  Hay  Fever."  It  is  not,  strictly 
speaking,  a  catarrhal  affection,  for  it  is  usually  unattended  by 
secretion,  and  the  prefix  "  Spring  "  is  misleading,  as  it  is  seen 
also  in  summer  and  autumn.  The  hay  harvest  is  the  most  com- 
mon period  for  it,  owing,  probably,  to  certain  minute  particles 
which  then  float  in  the  air. 

The  bulbar  conjunctiva  is  chiefly  affected.  It  becomes  injected, 
slightly  (Edematous,  and,  close  around  the  cornea,  somewhat  ele- 
vated, with  grayish  swellings.  The  margin  of  the  cornea  itself 
is  apt  to  become  invaded  with  minute  infiltrations. 

Some  individuals  are  liable  to  be  attacked  at  each  hay  har- 
vest. The  chief  symptoms  are  photophobia  and  lachrymation. 
The  affection  is  unattended  with  danger  to  the  eye. 

The  microscope  shows  (Uhthoff)  that  the  conjunctival  swell- 
ing is  due  to  hypertrophy  of  the  epithelial  layer  of  the  conjunc- 
tiva in  this  situation,  combined  with  sub-epithelial  infiltration 
with  a  substance  which  is,  or  is  similar  to,  coagulated  albumin. 
The  deeper  layers  of  the  conjunctiva  remain  tolerably  normal. 

Treatment — This  is  usually  an  excessively  troublesome  affec- 
tion to  cure.  Dark  glasses  for  protection  from  the  light,  weak 
astringent  collyria  (sulphate  of  zinc,  acetate  of  lead),  with  cold 


0»  DISEASES   OF   THE    EYE. 

sponging,  or  the  douche,  are  useful ;  or  iodoform  ointment  (1  in 
15),  a  little  put  into  the  eye  once  a  day.  Pagenstecher  highly 
recommends  massage  twice  daily  in  conjunction  with  strong  pre- 
cipitate ointment. 

Granular  Conjunctivitis,  Granular  Ophthalmia,  or  Trachoma 
(also  called  Egyptian  Ophthalmia  and  Military  Ophthalmia). — 
In  this  disease,  in  addition  to  the  usual  appearances  of  simple 
conjunctivitis,  there  are  developed  grayish,  or  pinkish-gray, 
bodies,  about  the  size  of  the  head  of  a  pin,  situated  in  and  close 
to  the  fornix  conjunctivae,  chiefly  of  the  upper  lid,  but  also  dis- 
seminated over  other  parts  of  the  membrane.  They  do  not 
form  on  the  bulbar  conjunctiva.  These  bodies  are  the  "gran- 
ules "  or  "  granulations,"  and,  in  the  acute  form  of  the  disease, 
they  somewhat  resemble  the  follicles  of  follicular  conjunctivitis, 
but  are  paler,  not  so  apt  to  occur  in  rows,  and  are  more  ispolated. 
Microscopically,  the  granulations  have  no  capsule,  as  have  the 
follicles,  but  seem  to  grow  from,  or  in,  the  stroma  of  the  con- 
junctiva. In  the  acute  form  the  granulations  consist  of  lymph 
cells  alone,  but  in  the  chronic  form  this  is  true  of  them  only 
toward  their  surface,  while  at  their  bases  they  are  formed 
chiefly  of  connective  tissue.  They  are  to  be  regarded  as  new 
growths  in  the  conjunctiva. 

The  disease  comes  under  our  notice  in  two  forms,  the  acute 
and  the  chronic.  The  latter  may  result  from  the  former,  but, 
more  commonly,  we  find  it  as  the  primary  condition,  without 
any  appreciable  acute  stage  having  gone  before. 

Causes. — Both  forms  are  contagious,  and,  probably,  the  infec- 
tion occurs  only  by  transference  of  the  secretion  from  one  eye 
to  the  other  by  means  of  fingers,  towels,  handkerchiefs,  etc. 
Hence,  the  more  slovenly  in  their  personal  habits,  and  the  more 
crowded  in  their  dwellings,  families,  schools,  regiments,  or  nations 
may  be,  the  more  likely  is  this  disease  to  spread  from  one  indi- 
vidual to  another  when  it  once  gains  a  foothold. 

It  has  been  stated  that  the  acute  form  is  often  epidemic  in 
places  where  the  hygienic  conditions  are  bad  ;  but  in  this  coun- 
try I  have  never  seen  it  as  an  epidemic,  and  sporadically  not 


THE   CONJUNCTIVA.  89 

often,  although  the  chronic  form  is  extremely  common  in  Ire- 
land. 

Amongst  the  better  classes,  here  and  elsewhere,  the  disease  is 
very  uncommon.  High,  dry,  mountainous  countries  are  almost 
free  from  this  disease.  So  that,  probably,  the  atmospheric  con- 
dititions  play  some  part  in  the  etiology. 

Some  hold  that  the  affection  is  dependent  on  constitutional 
disease,  such  as  scrofula,  tuberculosis,  syphilis,  etc.  ;  but  I  cannot 
indorse  this  view.  No  doubt  many  of  these  patients  are  aniemic 
and  out  of  health,  but  this  is  due  to  the  moping  habits  they  con- 
tract and  the  little  open-air  exercise  they  take,  in  consequence 
of  their  semi-blindness. 

Acute  Granular  Ophthalmia. — As  already  stated,  this  is  an 
affection  rarely  seen  in  this  country.  An  attack  commences 
with  swelling  of  the  upper  lid,  great  injection  of  the  whole  of 
the  bulbar  and  palpebral  conjunctiva,  and  swelling  of  the  papil- 
lae, with  development  of  the  characteristic  "granulations." 
There  may  be  but  little  discharge,  but  there  is  generally  much 
lachrymation,  with  photophobia  and  great  pain  in  the  brow  and 
eye.     Superficial  marginal  ulcers  of  the  cornea  may  form. 

The  inflammation  and  papillary  swelling  increase  for  a  week 
or  so,  to  such  a  degree  that  the  granulations  are  hidden  from 
view;  and  then,  taking  on  a  blenorrhreic  form,  the  process  grad- 
ually subsides,  until,  in  the  course  of  two  or  three  weeks  longer, 
it  disappears,  having  brought  about  absorption  of  the  granula- 
tions, and  ultimately  the  mucous  membrane  is  left  in  a  healthy 
state. 

If,  however,  in  the  blenorrhoeic  stage  the  inflammation  be  ex- 
cessive, the  eye  may  run  all  the  dangers  of  an  attack  of  acute 
purulent  conjunctivitis.  Or  if,  on  the  other  hand,  the  inflamma- 
tion be  very  slight,  it  may  not  be  sufficient  to  effect  absorption 
of  the  granulations,  and*  the  process  may  run  into  the  chronic 
form. 

Treatment. — It  is  desirable  to  abstain  from  active  measures  in 
the  commencement  of  the  affection,  owing  to  the  tendency  to 
natural  cure  which  is  often  present ;  and,  in  particular,  astringents 
8 


90  DISEASES   OF   THE   EYE. 

and  caustics  should  be  avoided.  At  the  utmost,  an  antiseptic 
lotion  of  boracic  or  salicylic  acid  and  cold  applications  for  relief 
of  the  pain  and  heat  are  admissible.  Dark  protection-glasses 
are  agreeable,  and,  wearing  them,  the  patient  should  be  encour- 
aged to  take  open-air  exercise.  But  if  it  be  evident  that  the 
inflammatory  reaction  is  not  active  enough,  poultices  or  warm 
fomentations  should  be  employed  to  promote  it.  Once  the  blen- 
norrhoeic  stage  has  been  reached,  great  care  is  required  to  control 
it ;  and,  if  it  threaten  to  exceed  safe  bounds,  it  must  be  restrained 
by  means  of  suitable  applications,  such  as  acetate  of  lead,  nitrate 
of  silver,  or  sulphate  of  copper  in  solutions  of  medium  strength  ; 
or  it  may  be  necessary  to  use  them  in  strong  solutions,  or  to  em- 
ploy the  solid  mitigated  nitrate  of  silver. 

Chronic  Granular  Ophthalmia. — The  first  onset  of  this  disease 
is  often  without  inflammation,  and  is  then  unattended  by  any  dis- 
tressing symptoms,  except  that  the  eye  may  be  more  easily  irri- 
tated by  exposure  to  cold  winds,  foreign  bodies,  etc.,  or  more 
easily  wearied  by  reading  or  other  near  work.  If  such  a  case 
come  under  our  notice,  the  conjunctiva  will  be  found  free  from 
injection  or  swelling,  but  grayish-white,  semi-transparent  granu- 
lations, of  the  size  of  a  rape-seed  and  less,  will  be  seen  disseminated 
over  the  conjunctival  surface  and  protruding  from  it.  Gradually 
these  granulations  give  rise  to  a  more  or  less  active  vascular 
reaction,  attended  with  swelling  of  the  papillae  and  purulent  dis- 
charge— in  short,  blennorrhoea.  The  patients  then  begin  to  be 
more  inconvenienced,  owing  to  the  discharge,  which  obscures 
their  vision,  and  to  sensations  of  weight  in  the  lids  and  of  foreign 
bodies  in  the  eye ;  and  this,  consequently,  is  generally  the  earliest 
stage  at  which  we  see  the  disease.  The  enlarged  papillae  some- 
times grow  to  a  great  size,  completely  hiding  the  granulations. 
In  this  stage  the  granulations  may  become  absorbed  and  the 
disease  undergo  cure;  but,  more  commonly,  it  makes  further 
progress.  Fresh  granulations  appear,  while  the  old  ones  increase 
in  size  until  they  often  become  confluent,  leaving  only  here  and 
there  an  island  of  vascular  mucous  membrane. 

These  chronic  granulations  consist  of  lymph-cells  toward  their 


THE   CONJUNCTIVA. 


91 


surface,  but  toward  their  bases  are  formed  chiefly  of  connective 
tissue.  Gradually  the  cellular  elements  are  transformed  into 
connective  tissue,  and  in  this  way  cicatricial  degeneration  of  the 
conjunctiva  is  brought  about  at  each  spot  where  a  granulation 
was  seated. 

Fig.  51. 


'^f%s^\M^':'^ 


n. 


'J^^m^l^^ 


a,  Muscle ;  b  b,  Tarsus  having  undergone  fatty  degeneration ;  c.  Atrophied  Meibomian 
Gland;  d  d,  Hypertrophied  Papilla;  e,  Cicatricial  Tissue  in  the  Conjunctiva; /,  Tar- 
sus.— Scemisch. 


As  the  disease  advances  the  submucous  tissue  becomes  impli- 
cated in  the  connective  tissue  alterations,  while  the  tarsus  under- 
goes fatty  degeneration  and  becomes  hypertrophied.     The  granu- 


92 


DISEASES   OF   THE   EYE. 


latioDS  disappear,  having  reduced  the  conjunctiva  to  a  cicatrix. 
Contraction  of  the  diseased  conjunctiva  on  the  inner  surface  of 
the  lid  causes  entropion  and  distortion  of  the  bulbs  of  the  eye- 
lashes, giving  rise  to  irregular  growth  of  the  latter,  with  resulting 
trichiasis  and  distichiasis.  These  changes  are  represented  in 
Fig.  51. 

The  great  danger  of  granular  ophthalmia  lies  in  the  complica- 
tions which  may  attend  it,  or  which  follow  in  its  wake.  The 
former  consist  in  pannus  and  ulcers  of  the  cornea,  and  severe 
purulent  conjunctivitis ;  while  the  latter  are  the  distortions  of  the 
lids  and  eyelashes  just  referred  to. 

Pannus  (Lat.,  a  cloth  rag)  presents  the  appearance  of  a  super- 
ficial vascularization  of  the  cornea,  with  more  or  less  diffuse 
opacity  and  often  small  infiltrations  (Fig.  52).  It  invariably 
commences  in  the  upper  portion  of  the  cornea,  extending 
generally  over  the  upper  half,  and  frequently  remains  confined 
to   this  region.      But  in  many  cases,  at  a  later  stage,  it  extends 

to  the  whole  sur- 
^^^•^2.  face  of  the  cornea, 

and  this  latter 
occurrence  often 
takes  place  almost 
suddenly,  and  the 
vascularization 
and  opacity  some- 
times become  so 
intense  as  to  pre- 
sent quite  a  fleshy 
appearance,  and 
to  completely 
hide  the  corres- 
ponding part  of  the  iris  from  view.  Histologically,  pannus 
consists  of  a  new  growth,  which  is  extremely  rich  in  cells, 
and  which  closely  resembles  the  conjunctiva  when  occupied  with 
confluent  granulations.  It  is  situated  between  the  corneal 
epithelium  and  Bowman's  layer,  and  is  permeated  by  vessels 


THE   CONJUNCTIVA.  93 

derived  from  the  coDJunctival  vessels.  After  a  length  of  time 
Bowman's  layer  becomes  destroyed  in  places,  and  then  the  cellu- 
lar infiltration  gains  access  to  the  true  cornea  and  gives  rise  to 
permanent  changes  in  its  transparency  and  curvature.  In  some 
bad  cases  of  old-standing  pannus  the  latter  undergoes  a  connect- 
ive-tissue change.  It  then  becomes  smooth  on  the  surface  and 
the  vessels  almost  disappear,  so  that  the  cornea  is  covered  with 
a  thin  layer  of  connective  tissue,  which  obstructs  the  passage  of 
light,  and  is  not  capable  of  cure. 

Another  result  of  pannus,  sometimes,  is  a  bulging  or  sta- 
phylomatous  condition  of  the  cornea,  the  tissues  of  which  have 
become  so  altered  that  they  give  way  before  the  normal  intra- 
ocular tension. 

A  pannus  in  which  as  yet  there  is  no  connective  tissue  altera- 
tion, and  where  there  is  no  staphylomatous  bulging,  is  capable 
of  undergoing  cure  without  leaving  any  opacity  behind,  except 
that  which  may  be  due  to  ulcers  that  have  been  present. 

Pannus  is  usually  a  painless  affection,  but  is  sometimes  accom- 
panied by  photophobia  and  ciliary  neuralgia.  It  may  come  on 
at  any  stage  of  the  disease,  and  causes  defective  vision  in  pro- 
portion to  the  degree  and  extent  of  the  opacity.  Severe  pannus 
is  liable  to  induce  iritis. 

The  connection  between  pannus  and  the  condition  of  the 
lids  is  not  altogether  evident.  It  is  held  by  many  that  this 
corneal  affection  is  due  to  mechanical  irritation,  caused  by  the 
rough  palpebral  conjunctiva ;  but  this  view  is  obviously  incor- 
rect, for  severe  pannus  is  often  seen  with  a  comparatively  smooth 
conjunctiva,  while  with  a  truly  rough  conjunctiva  the  cornea  is 
frequently  perfectly  clear.  But  there  can  be  little  doubt  that 
pannus  is  analogous  to  the  granular  disease  in  the  conjunctiva. 
It  is,  in  fact,  the  same  disease  modified  by  reason  of  the  different 
tissue  in  which  it  is  situated,  this  different  tissue  being  itself  a 
modification  of  the  conjunctiva;  and  it  would  seem  probable  that 
the  cornea  becomes  diseased  by  direct  inoculation  from  the  con- 
junctiva of  the  upper  lid.     Yet  it  is  remarkable  that  the  bulbar 


94  DISEASES   OF   THE    EYE. 

conjunctiva,  lying  between  the  upper  margin  of  the  cornea  and 
the  fornix  of  the  upper  lid,  never  becomes  diseased. 

Prognosis. — At  any  period  prior  to  cicatrization  of  the  con- 
junctiva an  attack  of  purulent  blennorrhoea  is  liable  to  come  on. 
If  not  too  severe,  this  may  result  in  a  cure  by  absorption  of  the 
granulations,  and  should  not  be  checked.  If,  however,  the 
attack  be  very  severe,  the  eye  runs  dangers  similar  to  those  of 
an  ordinary  attack  of  purulent  conjunctivitis.  These  dangers 
are  less  the  more  complete  and  the  more  intense  the  pannus. 

Ou  the  whole,  if  the  disease  come  under  treatment  at  an  early 
period,  it  may  be  hoped  that  vision  will  be  retained  in  a  major- 
ity of  cases,  although  a  radical  cure  may  be  difficult  or  impos- 
sible. These  cases  require  to  be  under  constant,  or  intermitting, 
treatment  for  long  periods,  often  for  years,  and  are  extremely 
liable  to  relapses. 

Treatment. — The  aim  of  this  is  to  bring  about  absorption  of 
the  granulations  with  the  greatest  possible  despatch,  in  order 
to  prevent  the  destruction  of  the  mucous  membrane  to  which 
they  tend.  No  caustic  application  should  be  made  with  the 
object  of  directly  destroying  the  granulations,  for  this  can  only 
be  done  at  the  expense  of  the  mucous  membrane  around  them. 
As  already  said,  in  cases  of  chronic  granular  ophthalmia  in 
which  a  blennorrhoeic  attack  comes  on,  when  this  passes  off  again 
the  granulations  are  found  to  have  become  much  fewer,  or  to 
have  quite  disappeared.  Following  the  hint  nature  thus  gives 
us,  we  should  endeavor  by  our  treatment  to  produce  a  certain 
papillary  reaction.  For  chronic  cases,  with  little  swelling  of  the 
papilke  (blennorrhoea),  and  with  little  or  no  cicatrization,  the 
best  application  is  the  solid  sulphate  of  copper  lightly  applied  to 
the  conjunctiva,  especially  at  its  fornix ;  but  when  there. is  con- 
siderable papillary  swelling  I  prefer  a  10-grain  solution  of  nitrate 
of  silver,  properly  neutralized  after  its  application  with  a  solu- 
tion of  salt,  or  a  light  application  of  mitigated  lapis,  similarly 
neutralized.  An  interval  of  twenty-four  hours  at  least  should 
be  allowed  to  elapse  between  each  application,  whether  of  sulphate 


THE   CONJUNCTIVA.  95 

of  copper  or  nitrate  of  silver,  and  cold  sponging  for  fifteen  min- 
utes should  be  employed  immediately  after  the  application.  A 
change  of  treatment  will  be  occasionally  required,  even  if  the 
remedy  first  used  answer  well  in  the  beginning,  and  one  or  other 
of  the  following  can  be  adopted:  Pure  carbolic  acid  liquefied 
has  been  used  *  with  good  results,  but  I  have  no  experience  of  it. 
It  is  applied  with  a  camel's-hair  pencil  and  the  excess  washed 
oflf  with  plain  water.  Liq.  plumb,  acetatis  dil.,  never  to  be  used 
except  with  everted  lids,  and  washed  off"  with  plain  water  by  the 
surgeon ;  and  not  even  in  this  way  if  there  be  ulcers  of  the 
cornea,  as  the  corneal  tissue  forming  the  floor  of  the  ulcer  is 
liable  to  become  impregnated  with  a  white  deposit,  probably  the 
albuminate  of  lead,  which  is  by  no  means  easy  to  remove  by 
operation  subsequently.  Tannin  ointment:  Tannin,  gr.  j,  to 
vaseline,  .^j,  the  size  of  half  a  pea,  to  be  put  into  the  eye  once  a 
day.  Sulphate  of  copper  ointment:  Same  strength  as  the  last, 
and  to  be  used  in  the  same  way.  Solution  of  alum  :  Gr.  x  to 
5j  of  distilled  water ;  one  drop  in  the  eye  once  a  day.  Where 
an  active  pannus  is  present  a  drop  of  solution  of  atropine  should 
be  instilled  into  the  eye  once  a  day  as  a  precaution  against  iritis. 

Some  surgeons  employ  scarifications  of  the  conjunctiva  when  it 
is  much  swollen  and  the  papillse  too  exuberant,  but  I  have  never 
adopted  them,  fearing  the  resulting  cicatrices. 

Again,  it  has  been  proposed  to  excise,  or  abscise,  the  granula- 
tions, and  this  may,  perhaps,  be  allowable  if  they  are  isolated  and 
protrude  much  over  the  surface  of  the  conjunctiva. 

Squeezing  out  the  granulations  between  the  thumb-nails  used 
to  be  practiced  by  the  late  Sir  AVilliam  Wilde,  of  Dublin,  and 
has  recently  again  come  into  use.  But  the  proceeding  of  expres- 
sion is  nowadays  performed  by  means  of  an  instrument  instead 
of  by  the  finger-nails.  The  best  instrument  for  the  purpose  is 
Knapp's  roller  forceps  f  (Fig.  52  a).     Two  small  grooved  cylin- 


*  Recently  again  by  E.  Treacher  Collins,  Roy.  Lond.  Ophthal.  Hosp. 
Rep.,  Vol.  xi,  p.  340. 

t  Trans.  Anier.  Ophthal.  See.  for  1891. 


yb  DISEASES   OF   THE    EYE, 

ders  are  inserted  in  the  forked  ends  of  a  strong  forceps,  so  that 
they  roll  over  the  surfaces  of  a  body  which  may  be  grasped  be- 
tween them  when  the  instrument  is  drawn  upon.  The  retro- 
tarsal  fold  of  the  lower  or  upper  lid  is  grasped  as  far  back  as 
possible  between  the  cylinders,  compressed  and  drawn  upon,  and 
in  this  way  the  granulation  tissue  is  squeezed  out  without  lacer- 
ation of  the  conjunctiva.  The  instrument  has  to  be  reinserted 
and  a  neighboring  part  of  the  conjunctiva  treated  in  the  same 
way,  and  so  on  until  the  whole  conjunctiva  of  each  affected  eye- 
lid has  been  operated  on.  The  four  eyelids  may  be  manipulated 
at  one  sitting,  and  the  evacuation  should  be  so  complete  that  a 
repetition  of  the  proceeding  will  not  be  required.  Particular 
care  should  be  taken  to  reach  the  part  of  the  conjunctiva  which 
is  hidden  under  the  commissures.     If  the  tarsal  portions  are  af- 

FiG.  52  A. 


fected,  one  cylinder  may  be  applied  to  the  outer  surface  of  the 
lid,  and  the  instrument  so  drawn  across  the  lid  that  the  other 
cylinder  presses  the  granulations  out  of  the  tarsal  conjunctiva. 
As  the  operation  is  painful,  and  cocaine  not  of  much  avail  in  it, 
it  is,  as  a  rule,  desirable  that  the  patient  should  be  under  the 
influence  of  an  amesthetic.  Some  cases  are  immediately  and 
permanently  cured  by  this  operation,  while  others,  although 
greatly  benefited,  will  still  require  a  further  routine  treatment 
with  local  remedies.  My  experience  with  this  method  leads  me 
to  regard  it  as  a  most  valuable  one  for  the  cure,  or  for  the  accel- 
eration of  the  cure,  of  granular  ophthalmia  before  the  cicatricial 
stage  has  come  on. 

Excision   of  the   fornix    conjunctivae    has    been  proposed    by 
Schneller,*  and  largely  practiced  by  him  and  other  surgeons.     It 


*  Von  Graefe^s  Archiv,  Vol.  xxx,  No.  4,  p.  131,  and  Vol.  xxxiii,  No. 
3,  p.  113. 


THE    CONJUNCTIVA.  97 

is  claimed  for  this  method :  That  it  shortens  the  treatment  of  all 
forms  of  the  disease;  that,  after  it,  existing  corneal  processes 
undergo  rapid  cure;  that  the  granular  disease  in  the  palpebral 
conjunctiva,  although  not  directly  included  in  the  operation,  dis- 
appears quickly ;  that  recurrences  of  the  disease  are  rarer  than  by 
other  plans  of  treatment;  and  that  the  linear  cicatrix  which  results 
has  no  serious  consequence,  and  is  as  nothing  when  compared  with 
the  extensive  cicatricial  degeneration  of  the  whole  mucous  mem- 
brane, which  the  operation  is  calculated  to  prevent.  Supplemental 
treatment  with  the  customary  local  applications  is  employed  until 
the  cure  is  obtained.  I  have  myself  but  little  experience  of 
this  method. 

Infusion  of  Jequirity  (Abrus  vrecatorius,  Paternoster  Bean), 
long  used  in  the  Brazils,  has  been  introduced  to  the  notice  of 
European  surgeons  by  de  Wecker.  The  infusion  is  made  by 
macerating  154  grains  of  the  decorticized  jequirity  seeds  in  16 
oz.  of  cold  water  (a  3  per  cent,  infusion)  for  twenty-four  hours. 
Twice  a  day,  for  three  days,  the  lids  are  everted  and  the  infusion 
thoroughly  rubbed  into  the  conjunctiva  with  a  sponge  or  bit  of 
lint.  The  result  is  a  severe  conjunctivitis  of  a  somewhat  croupous 
tendency  (even  the  cornea  being  often  hidden  by  the  false  mem- 
brane), accompanied  by  great  swelling  of  the  eyelids,  much  pain, 
and  considerable  constitutional  disturbance,  rapid  pulse,  and 
temperature  of  100°  or  more.  In  the  course  of  eight  or  ten 
days  the  inflammation  subsides,  and  the  cornea  in  many  cases 
will  then  be  found  to  be  free  from  pannus,  or  almost  so,  while 
complete  cure  of  the  granular  ophthalmia  itself  is  rarer.  Iced 
compresses  to  the  eyelids  should  be  used  during  the  inflammation. 
Afresh  infusion  (not  more  than  seven  days  old)  must  be  em- 
ployed in  order  to  secure  the  best  reaction.  The  majority  of 
surgeons,  amongst  them  myself,  find  the  remedy  harmless,  if  not 
always  successful  ;  but  a  good  many  cases  are  on  record  where 
violent  diphtheritic  conjunctivitis,  followed  by  blennorrhoea  of  the 
conjunctiva  and  by  more  or  less  extensive  ulceration  of  the 
cornea,  and  even  complete  loss  of  the  eye,  was  produced.  I  have 
two  or  three  times  seen  a  small  superficial   ulcer  form  on  the 


98  DISEASES   OF   THE    EYE. 

lower  third  of  the  cornea  without  further  iujury.  De  Wecker 
regards  the  presence  of  a  purulent  discharge  from  the  conjunc- 
tiva as  a  contra-indication  for  the  remedy,  which  he  finds  is  then 
liable  to  increase  the  intensity  of  the  blennorrhoea  in  a  dangerous 
degree.  Cases  where  there  is  little  or  no  papillary  swelling,  but 
nearly  dry  granulations  withpannus,  are  the  most  suitable  for  its 
use,  and  I  cannot  recommend  it  too  highly  in  these  cases.  It  is 
marvelous  to  see  the  rapid  and  beautiful  cures  of  the  severest 
pannus  by  this  remedy,  in  properly  selected  cases.  But  the 
presence  of  well-marked  pannus  of  the  cornea  without  ulceration 
is,  I  think,  the  only  thing  that  can  render  the  employment  of 
jequirity  justifiable,  and,  in  addition  to  this,  the  conjunctiva 
should  be  free  from  blennorrhoea. 

The  occurrence  of  acute  dacryocystitis  sometimes  forms  an  un- 
pleasant complication  of  the  jequirity  treatment,  even  in  cases  in 
which  the  sac  was  previously  quite  normal,  but  I  have  never  my- 
self seen  it  to  occur. 

After  the  subsidence  of  the  jequirity  inflammation,  some  of 
the  local  remedies  above  referred  to  should  be  regularly  applied, 
for  the  purpose  of  completing  the  cure  of  the  conjunctival  con- 
dition. 

Besides  local  remedies,  it  is  of  great  importance  that  the 
hygienic  surroundings  of  patients  suffering  from  granular 
ophthalmia  be  seen  to,  and  that  they  be  obliged  to  spend  a  con- 
siderable time  daily  in  the  open  air. 

If  the  upper  lid  be  tightly  pressed  on  the  globe,  for  this 
pressure  varies  in  different  individuals,  an  impediment  is  ofi*ered 
to  the  cure  by  any  method,  and  pannus  is  promoted.  It  is  then 
necessary  to  relieve  the  pressure  by  a  canthoplastic  operation. 
(See  Chap.  VI.) 

Peritomy. — This  procedure  is  for  the  cure  of  pannus  by 
destruction  of  the  vessels  which  supply  it,  and  is  as  follows: 
About  5  mm.  from  the  margin  of  the  cornea  an  incision  is  made 
in  the  conjunctiva  with  scissors,  and  carried  at  this  distance  all 
the  way  round  the  cornea.  This  ring  of  conjunctival  tissue  is 
then  separated  up  from  the  sclerotic  and  cut  off  at  the  corneal 


THE    CONJUNCTIVA.  99 

margin  ;  and  the  underlying  connective  tissue  is  dissected  off  the 
corresponding  portion  of  the  sclerotic,  which  is  thus  laid  quite 
bare.  The  proceeding  is  not  always  satisfactory,  and  of  late 
years  I  have  practiced  it  but  little. 

Acute  Blennorrhoea  of  the  Conjunctiva,  or  Purulent  Ophthal- 
mia.— We  most  commonly  find  this  very  dangerous  affection 
either  as  gonorrhoeal  ophthalmia  or  as  blennorrhoea  neona- 
torum. 

Etiology. — In  the  former,  the  etiological  moment  is  the  intro- 
duction of  some  of  the  specific  discharge  from  the  urethra  or 
vagina  into  the  conjunctival  sac ;  while,  in  the  latter,  the  infec- 
tion is  believed  to  take  place  either  du'ring  or  just  after  the  pass- 
age of  the  head  through  the  vagina  by  an  abnormal  secretion 
from  the  latter  finding  its  way  into  the  infant's  eyes.  Inocula- 
tion may  also  occur  a  few  days  after  birth  by  pus  conveyed  by 
the  fingers  of  the  mother  or  nurse,  or  by  towels,  etc.,  used  for 
washing  the  child's  face.  It  is  never  due  to  exposure  to  strong 
light  or  to  cold,  as  is  popularly  supposed. 

The  more  severe  cases  of  blennorrhoea  neonatorum  are  caused 
by  a  vaginal  discharge,  which  is  always  gonorrho?al.  Xeisser, 
who  first  observed  the  presence  of  a  peculiar  micrococcus  in  the 
gonorrhoeal  discharge,  also  found  the  gonococcus  in  the  pus  from 
the  conjunctiva  in  cases  of  gonorrhoeal  ophthalmia,  and  the 
same  micrococcus  has  been  found  in  the  conjunctival  discharge 
in  cases  of  blennorrhoea  neonatorum.  But  the  slight  cases  of 
the  latter  affection,  which  amount  to  little  more  than  a  catarrh 
of  the  conjunctiva,  may  be  caused  by  a  vaginal  discharge  which 
is  not  of  the  specific  gonorrhoeal  nature. 

If  the  infection  take  place  during  or  immediately  after  birth, 
the  disease  appears  from  the  second  to  the  fifth  day,  according 
to  the  virulence  of  the  secretion.  If  the  inflammation  come  on 
later  than  the  fifth  day,  it  may  be  concluded  that  the  infection 
was  produced  by  the  vaginal  discharge  being  introduced  into 
the  eye  by  the  fingers  of  the  mother  or  nurse,  etc.  Acute  con- 
junctival blennorrhoea  also  comes  about  without  any  assignable 
cause ;  but,  in  all  such  cases,  it  may  be  regarded  as  certain  that 


100  DISEASES   OF   THE   EYE. 

the  introduction  of  some  infective  pus  into  the  eye  has  taken 
place,  although  without  the  knowledge  of  the  patient. 

Symptoms  and  Progress. — In  mild  cases  the  bulbar  conjunctiva 
may  be  but  little  or  not  at  all  affected,  the  palpebral  conjunc- 
tiva alone  becoming  velvety  and  discharging  a  small  amount  of 
pus,  while  there  may  be  no  swelling  or  oedema  of  the  eyelids. 
Such  mild  cases  are  not  uncommon  in  ophthalmia  neonatorum. 
In  severe  cases  of  blennorrhoea  of  the  conjunctiva  there  is,  soon 
after  the  onset,  serous  infiltration  of  the  palpebral  mucous  mem- 
brane— which,  consequently,  becomes  tense  and  shiny — serous 
chemosis  (/a:Vo>»,  to  gape  open  *)  of  the  bulbar  conjunctiva, 
serous  discharge,  dusky  redness  and  swelling  of  the  eyelids — 
which  makes  it  difficult  to  evert  them — pain  in  the  eyelids,  often 
of  a  shooting  kind,  burning  sensations  in  the  eye,  and  photo- 
phobia. This  first  stage  lasts  from  forty-eight  hours  to  four  or 
five  days. 

Then  begins  the  second  stage,  in  which,  owing  to  swelling  of 
the  papilke,  the  palpebral  conjunctiva  becomes  less  shiny  and 
more  velvety,  while  the  discharge  alters  from  serous  to  the 
characteristic  purulent  form,  the  chemosis,  however,  remaining 
unaltered,  or  becoming  more  firm  and  fleshy.  The  swelling  of 
the  lids  continues,  the  upper  lid  often  becoming  pendulous  and 
hanging  down  over  the  under  lid,  while  at  the  same  time 
it  becomes  less  tense  and  more  easily  everted.  Gradually  the 
chemosis  and  swelling  of  the  conjunctiva  and  eyelids  subside,  and 
the  discharge  lessens,  the  mucous  membrane  finally  being  left  in 
a  normal  state,  unless  in  a  small  percentage  of  cases  in  which 
chronic  blennorrhoea  remains.  A  moderately  severe  attack  of 
conjunctival  blennorrhoea  lasts  from  four  to  six  weeks. 

Complications  with  corneal  affections  form  the  great  source  of 
danger  from  this  affection.  They  occur  in  four  different  forms  : 
I.  Small  epithelial  losses  of  substance  on  any  part  of  the  cornea. 
If  these  occur  at  the  height  of  the  inflammation,  they  are  apt  to 

*  Probably  from  the  appearance  produced  when  the  conjunctiva  in  this 
condition  is  much  elevated  round  the  margin  of  the  cornea. 


THE   CONJUNCTIVA.  101 

go  on  to  form  deep  perforating  ulcers.  2.  The  whole  cornea 
becomes  opaque  (diffusely  infiltrated),  and  toward  its  centre 
some  grayish  spots  form,  which  are  interstitial  abscesses  or  puru- 
lent infiltrations.  3.  The  infiltration  may  form  at  the  margin  of 
the  cornea,  and  extend  a  considerable  distance  around  its  circum- 
ference, giving  rise  to  a  marginal  ring  ulcer,  and,  later  on,  to 
sloughing  of  the  whole  cornea.  4.  A  clean-cut  ulcer  may  form 
at  the  margin  of  the  cornea  without  any  purulent  infiltration  of 
the  corneal  tissue,  and  may  also  extend  a  long  way  round  the 
cornea.  Such  ulcers  are  particularly  apt  to  occur  where  there 
is  much  chemosis  which  overlaps  the  margin  of  the  cornea;  and, 
being  hidden  in  this  way,  these  ulcers  are  easily  overlooked. 
The  chemosis  should  be  pushed  aside  with  a  probe,  and  these 
peculiar  ulcers  looked  for.     They  are  very  liable  to  perforate. 

All  the  foregoing  forms  of  corneal  complication  occur  both  in 
ophthalmia  neonatorum  and  in  gonorrhceal  ophthalmia.  They 
may  appear  at  any  period  of  the  affection,  but  the  earlier  they 
occur,  the  more  likely  are  they  to  result  seriously. 

The  danger  of  these  ulcers  consists  in  the  perforation  of  the 
cornea  they  are  apt  to  produce,  of  which  more  later  on. 

The  severer  the  case,  especially  the  more  the  bulbar  conjunc- 
tiva is  involved  in  the  process,  the  more  likely  is  it  that  corneal 
complications  will  arise.  For  the  corneal  process  is  to  be  re- 
garded as  the  result  of  infection  by  the  conjunctival  secretion  ;  and 
this  infection  is  all  the  more  apt  to  occur  where  the  nutrition  of 
the  cornea  is  impeded  by  a  dense  chemotic  swelling  of  the  bulbar 
conjunctiva.  Severe  chemosis  is  less  common  in  the  blennorrhoea 
of  the  new-born  than  in  gonorrheal  ophthalmia,  and  this  is  the 
chief  reason  for  the  fact  that  the  latter  is  the  more  dangerous 
affection  of  the  two. 

Treatment. — The  prophylaxis  of  purulent  ophthalmia  must 
here  first  engage  our  attention. 

The  prophylaxis  of  blennorrhoea  neonatorum  is  a  most  impor- 
tant matter,  and  should  form  part  of  the  routine  of  lying-in 
practice.  Careful  disinfection  of  the  vagina  before  and  during 
birth,  and  the  most  minute  care  in  cleansing  the  face  and  eyes  of 


102  DISEASES   OF   THE   EYE. 

the  infant  immediately  after  birth  with  a  non-irritating  disinfect- 
ant {e.g.,  a  solution  of  corrosive  sublimate  1  in  5000)  are  to 
be  recommended.  The  method  of  Dr.  Crede  has  found  very 
general  acceptance,  and  is  a  good  one.  It  is  as  follows:  When, 
after  division  of  the  umbilical  cord,  the  child  is  in  the  bath,  the 
eyes  are  carefully  washed  with  water  from  a  separate  vessel,  the 
lids  being  scrupulously  freed,  by  means  of  absorbent  wool,  of  all 
blood,  slime,  or  smeary  substance;  and  then,  before  the  child  is 
dressed,  a  few  drops  of  a  2  per  cent,  solution  of  nitrate  of  silver 
are  instilled  into  the  eye.  Dr.  Crede  and  many  other  obstetri- 
cians employ  this  method  now,  in  a  routine  manner,  in  their 
lying-in  hospitals,  for  all  the  infants,  whether  or  not  it  be  sus- 
pected that  there  is  danger  of  infection ;  and  by  its  aid  Crede 
reduced  the  percentage  of  his  cases  of  ophthalmia  neonatorum 
from  8  or  9  per  cent,  to  0.5  per  cent. 

The  action  of  the  nitrate  of  silver  solution  depends,  probably, 
upon  the  destruction  of  the  superficial  layers  of  the  conjunctival 
epithelium  and  of  the  gouococci  contained  in  them.  Other  anti- 
septic applications  which  have  been  tried  do  not  act  as  well,  for 
they  do  not  destroy  the  superficial  epithelium. 

In  all  cases  of  gonorrhoea  it  is  the  duty  of  the  surgeon  to  ex- 
plain to  his  patients  what  is  the  danger  of  their  carrying  any  of 
the  urethral  discharge  to  their  eyes,  and  to  charge  them  to  exer- 
cise punctilious  cleanliness  as  regards  their  hands  and  finger- 
nails, and  care  in  the  use  of  towels,  handkerchiefs,  etc. 

In  respect  of  Local  Treatment  when  the  disease  has  once  broken 
out :  in  the  commencement  of  the  affection,  the  only  local  appli- 
cations admissible  are  antiseptic  lotions  (boric  acid,  corrosive 
sublimate)  and  iced  compresses,  or  Leiter's  tubes.  With  the 
former  the  conjunctival  sac  should  be  freely  washed  or  irrigated, 
not  syringed  out.  In  syringing  out  the  conjunctival  sac,  a 
morsel  of  the  corneal  epithelium  may  be  removed,  and  through 
this  the  cornea  become  infected,  and  therefore  this  method  is 
objectionable.  The  iced  compresses,  or  Leiter's  tubes,  should  be 
kept  to  the  eye  for  an  hour  at  a  time,  with  a  pause  of  an  hour, 
and  so  on ;  or  even  continuously.     In  this  and  in  the  next  stage 


THE    CONJUNCTIVA.  103 

the  cheraosis  should  be  freely,  and  daily,  incised  with  scissors. 
If  the  swelling  of  the  lids  be  great,  the  external  canthus  should 
be  divided  with  a  scalpel,  from  without,  leaving  the  conjunctiva 
uninjured,  in  order  to  reduce  the  tension  of  the  eyelids  on  the 
globe,  and,  by  bleeding  from  the  small  vessels,  to  deplete  the 
conjunctiva.  Depletion  alone  can  be  obtained  by  leaching  at  the 
external  canthus,  and,  in  many  cases,  is  of  great  benefit  at  the 
very  commencement.  If,  ia  adults,  the  chemosis,  palpebral 
swelling,  and  rapidity  of  the  onset,  indicate  that  the  inflammation 
is  severe,  it  is,  in  my  opinion,  well  to  place  the  patient  quickly 
under  the  influence  of  mercury  by  means  of  inunctions,  or  small 
doses  of  calomel,  as  by  this  means  the  chemosis  is  often  rap- 
idly brought  down  and  one  source  of  danger  to  the  cornea  re- 
moved. 

In  the  second  stage,  i.  e.,  when  the  conjunctiva  has  become 
velvety  and  the  discharge  purulent,  caustic  applications  are  the 
most  trustworthy,  and  in  this  respect  iodoform  and  other  lauded 
means  cannot  compete  with  them.  The  application  employed 
may  be  a  solution  of  nitrate  of  silver  of  15  to  20  grains  in  5J  of 
water,  which  should  be  applied  by  the  surgeon  to  the  conjunctiva 
of  the  everted  lids  and  then  neutralized  with  a  solution  of  com- 
mon salt,  as  described  when  discussing  the  treatment  of  simple 
catarrhal  conjunctivitis.  Or,  the  solid  mitigated  nitrate  of  silver 
(one  part  nitrate  of  silver,  two  parts  nitrate  of  potash)  may  be 
used,  the  first  application  being  mild,  in  order  to  test  its  effect, 
while  careful  neutralization  with  salt  water  and  subsequent  wash- 
ing with  fresh  water  are  most  important. 

The  immediate  effect  of  a  caustic  application  to  the  conjunc- 
tiva is  the  production  of  a  more  or  less  deep  slough,  under  which 
a  serous  infiltration  takes  place.  This  latter  increases,  and  finally 
throws  oflT  the  slough,  and  then  the  epithelium  begins  to  be  re- 
formed. From  the  time  the  slough  separates  until  the  epithelium 
has  been  regenerated,  a  diminution  in  the  secretion  may  be 
noted,  but  the  discharge  again  increases  as  soon  as  the  regener- 
ative period  is  ended,  and  this  now  is  the  moment  for  a  new 
application    of  the   caustic.     From    one    caustic  application  of 


104  DISEASES   OF   THE   EYE. 

ordinary  severity  until  the  end  of  the  regenerative  period  about 
twenty-four  hours  usually  elapse.  Inamediately  after  a  caustic 
application  iced  compresses  should  be  used  for  thirty  minutes  or 
longer.  Between  the  caustic  applications  the  pus  should  be  fre- 
quently washed  away  from  the  eyelids,  and  from  between  the 
eyelids,  with  a  4  per  cent,  solution  of  boric  acid,  or  with  a  1  in 
5000  solution  of  corrosive  sublimate,  and  boric  acid  ointment 
should  be  smeared  along  the  palpebral  margins  to  prevent  them 
from  adhering  and  thus  retaining  the  pus. 

No  corneal  complication  contraindicates  the  active  treatment 
of  the  conjunctiva  by  the  method  just  described.  Iodoform, 
finely  pulverized,  has  been  much  praised  as  a  local  application  in 
the  second  stage  of  acute  blennorrhoea  of  the  conjunctiva.  It  is 
to  be  dusted  freely  on  the  conjunctiva  once  or  twice  a  day.  For 
my  part,  I  should  trust  to  it  in  mild  cases  only. 

When  one  eye  is  affected,  it  is  important  to  protect  its  fellow 
from  infection  by  means  of  a  hermetic  bandage.  This  may  be 
made  by  applying  to  the  eye  a  piece  of  lint  covered  with  boracic 
acid  ointment,  and  over  this  a  pad  of  borated  cotton  wool. 
Across  this,  from  forehead  to  cheek  and  from  nose  to  temporal 
region,  are  laid  strips  of  lint  soaked  in  collodion  in  layers  over 
each  other ;  or  a  piece  of  tissue  gutta-percha  may  take  the  place 
of  the  lint  and  collodion,  its  margins  being  fastened  to  the  skin  by 
collodion.  The  shields  invented  by  Maurel  and  by  Buller  are 
very  serviceable  for  this  purpose. 

Treatment  of  Corneal  Complications. — Many  surgeons,  I  under- 
stand, use  solution  of  the  sulphate  of  eserine  (gr.  ij  ad  aq.  f.^j) 
dropped  into  the  eye  as  soon  as  any  corneal  complication  arises, 
and  as  long  as  it  continues,  on  the  ground  that  this  drug  is  be- 
lieved to  have  the  effect  of  reducing  the  intra-ocular  tension  (a 
circumstance  to  be  desired  in  these  instances),  and  also  to  act  as 
an  antiseptic.  Its  power  to  reduce  the  normal  intra-ocular 
tension  is  not  great,  and  its  antiseptic  action,  if  it  exist,  must  be 
very  insignificant,  while,  in  my  opinion,  it  has  a  decided  tendency 
to  promote  iritis  in  these  cases,  where  the  iris  is  liable  to  become 
inflamed  secondarily  to  the  corneal  process.     I  therefore  do  not 


THE   CONJUNCTIVA.  105 

recommend  its  use  in  these  cases.  I  employ  atropine  here  with 
the  object  of  diminishing  the  tendency  to  iritis.  Only  if  a 
marginal  ulcer  should  perforate,  with  prolapse  or  danger  of  pro- 
lapse into  the  opening,  is  eserine  indicated,  and  then  simply  for 
the  purpose  of  drawing  the  iris  out  of  or  away  from  the  perfora- 
tion, by  the  contraction  of  its  sphincter. 

On  the  first  appearance  of  an  ulcer  or  infiltration  of  the  cor- 
nea, besides  the  use  of  atropine,  nothing  can  be  done  further 
than  the  steady  continuance  of  the  conjunctival  treatment,  no 
remission  or  relaxation  of  which  is  indicated,  or,  indeed, 
admissible.  Greater  care  is  now  required  in  everting  the  lids, 
lest  pressure  on  the  globe  might  cause  rupture  of  the  ulcer  ;  and 
it  should  be  remembered  that,  when  a  case  of  acute  blennorrhoea 
first  presents  itself,  the  surgeon,  not  knowing  the  condition  of  the 
cornea,  must  use  the  utmost  caution  in  making  his  examination, 
and  yet  must  never  fail  to  get  a  view  of  the  cornea,  for  the  pur- 
poses both  of  prognosis  and  of  treatment.  At  each  visit  the 
cornea  must  be  examined,  and  it  may  be  found  that,  as  the 
conjunctival  process  subsides,  any  existing  corneal  affection 
also  progresses  toward  cure,  infiltrations  becoming  absorbed  and 
ulcers  filled  up.  But,  even  though  the  conjunctiva  be  improving, 
and  still  more  so  if  it  be  not,  the  corneal  process  may  progress, 
the  infiltration  becoming  an  ulcer,  and  the  ulcer  becoming 
gradually  deeper,  until,  finally,  it  perforates. 

Should  a  corneal  ulcer  become  deep,  and  seem  to  threaten  to 
perforate,  paracentesis  of  the  floor  of  the  ulcer  must  be  resorted 
to  without  delay.  By  thus  forestalling  nature,  a  short  linear 
opening  is  substituted  for  the  circular  loss  of  substance  which 
would  have  resulted  in  the  ordinary  course  of  events.  Through 
this  small  linear  opening  no  prolapse  of  the  iris,  or  else  a  rela- 
tively small  one,  takes  place;  and,  consequently,  the  ultimate 
state  of  the  eye  is  usually  a  better  one  than  it  would  otherwise 
be.  The  reduction  of  the  intra-ocular  tension  after  the  para- 
centesis promotes  healing  of  the  ulcer.  It  is  often  desirable  to 
evacuate  the  aqueous  humor  by  opening  the  little  incision  in  the 


106  DISEASES   OF   THE    EYE. 

floor  of  the  ulcer  with  a  blunt  probe,  on  each  of  the  two  days 
after  the  operation. 

If  an  ulcer  perforate  spontaneously,  the  aqueous  humor  is 
evacuated,  and,  unless  the  ulcer  be  opposite  the  pupil  and  at  the 
same  time  small  in  size,  the  iris  must  come  to  be  applied  to  the 
loss  of  substance.  Should  the  latter  be  very  small,  the  iris  will 
simply  be  stretched  over  it  and  pass  but  little  into  its  lumen,  and, 
when  healing  takes  place,  will  be  caught  in  the  cicatrix,  which  is 
but  slightly  or  not  at  all  raised  over  the  surface  of  the  cornea, 
and  the  resulting  condition  is  called  Anterior  Synechia. 

If  the  perforation  be  larger,  a  true  prolapse  of  a  portion  of  the 
iris  into  the  lumen  of  the  ulcer  takes  place.  This  prolapse  may 
either  act  as  a  plug,  filling  up  the  loss  of  substance  and  keeping 
back  the  contents  of  the  globe,  but  not  protruding  over  the  level 
of  the  cornea,  or  it  may  bulge  out  over  the  corneal  surface  as  a 
black  globular  swelling,  and  may  then  play  the  part  of  a  dis- 
tensor  of  the  opening,  causing  fresh  infiltration  of  its  margins. 
In  either  case  cicatrization  will  eventually  occur ;  and  if  the 
scar  be  fairly  flat  it  is  called  an  Adherent  Leucoma,  but  if  it 
be  bulged  out  the  term  Partial  Staphyloma  of  the  Cornea  is 
used. 

If  the  perforation  be  very  large,  involving  the  greater  part  of 
the  cornea  with  prolapse  of  the  whole  iris  and  closure  of  the 
pupil  by  exudation,  the  result  is  a  Total  Staphyloma  of  the 
Cornea.  The  lens  may  lie  in  this  staphyloma,  or  it  may  retain 
its  normal  position,  but  become  shrunken. 

The  question  of  the  treatment  of  a  recent  prolapse  of  the  iris 
in  cases  of  blennorrhoeic  conjunctivitis  is  an  important  one.  It 
has  been,  and  is  still  largely,  the  practice  to  abscise  small  iris- 
protrusions  down  to  a  level  with  the  cornea ;  or,  if  large,  to  cut 
a  small  bit  off"  their  summits  with  the  object  of  obtaining  flat 
cicatrices.     Horner  "^  pointed  out  that,  in  cases  of  blennorrhoea, 

*  Gerhardt's  "Handbuch   der  Kinderkrankheiten,"  Bd.  v,  Abth.  2, 

p.  268. 


THE   CONJUNCTIVA.  107 

this  proceediDg  opens  a  way  for  purulent  infection  of  the  deep 
parts  of  the  eye,  and  that  serious  consequences  are  not  rare.  He 
confined  interference  with  the  iris  in  these  eyes  to  incision  of  the 
prolapse,  when  it  seems  to  be  acting  as  a  distensor  of  the  open- 
ing, causing  fresh  infiltration  of  the  cornea.  Under  other  cir- 
cumstances he  restricted  his  treatment  of  the  prolapse  to  the 
instillation  of  eserine,  which  has  a  marked  effect  in  diminishing 
the  size  of  the  protrusion. 

It  may  occur  that  on  the  surgeon's  visit  to  a  case  of  blennor- 
rhoea  of  the  conjunctiva  he  will  find  the  margins  of  the  eyelids 
gummed  together  by  sero-purulent  secretion,  while  the  eyelids 
are  bulged  out  by  the  pent-up  fluid  behind  them.  The  attempt 
to  open  the  eye  should  then  be  very  cautiously  made,  lest  some 
of  the  retained  pus  spurt  into  the  surgeon's  eye.  The  surgeon 
should  also  be  most  careful  to  thoroughly  wash  and  disinfect  his 
hands  and  nails  at  the  conclusion  of  his  visit. 

In  cases  of  blennorrhoea  neonatorum,  when  the  ulcer  has  been 
small,  on  perforation  taking  place,  the  lens,  or  rather  its  anterior 
capsule,  comes  to  be  applied  to  the  posterior  aspect  of  the  cornea. 
The  pupillary  area  is  soon  filled  with  fibrinous  secretion.  The 
opening  in  the  cornea  ultimately  becoming  closed,  the  iris  and 
lens  are  pushed  back  into  their  places  by  the  aqueous  humor, 
which  has  again  collected.  Adherent  to  the  anterior  capsule  on 
the  spot  which  lay  against  the  cornea  is  a  morsel  of  fibrin,  which 
gradually  becomes  absorbed  by  the  aqueous  humor.  In  the  mean- 
time changes  have  been  produced  by  this  exudation  on  the  corres- 
ponding intra-capsular  cells,  which  result  in  a  small,  permanent, 
central  opacity  at  that  place,  where  there  is  also  a  slight  eleva- 
tion of  pyramidal  shape  over  the  level  of  the  capsular  surface. 
This  condition  is  called  central  capsular  cataract,  or  pyramidal 
cataract,  and  rarely  results  from  corneal  perforation  in  adults. 

In  cases  of  blennorrhoea  nepnatorum  an  inflammatory  swelling 
of  the  joints,  so-called  gonorrhoeal  arthritis,  is  very  occasionally 
seen.     Deutschmann  *  found  the  gonococcus  in  the  fluid  removed 

^  Arch,  filr  Ophthal.,  xxxvi,  1,  p.  109. 


108  DISEASES   OF   THE   EYE. 

from  the  joints  in  two  such  cases,  while  other  observers  found  in 
their  cases  only  the  usual  pyogenic  cocci. 

Croupous  Conjunctivitis. — This  is  a  disease  of  early  childhood, 
and  is  not  common.  The  palpebral  conjunctiva  is  a  good  deal 
swollen,  and  is  covered  with  a  false  membrane  that  may  be 
peeled  off,  leaving  a  mucous  surface  underneath,  which  bleeds 
little  or  not  at  all.  The  disease  is  not  a  severe  one,  and  does 
not  cause  secondary  corneal  affections  unless  when  the  bulbar 
conjunctiva  very  rarely  participates  in  the  attack.  It  must  not 
be  mistaken  for  diphtheritic  conjunctivitis,  from  which  it  is  read- 
ily distinguished  by  the  ease  with  which  in  it  the  false  membrane 
can  be  removed,  and  by  the  vascular  condition  of  the  underlying 
mucous  membrane. 

This  is,  in  fact,  nothing  more  than  a  severe  form  of  catarrhal 
conjunctivitis,  in  which  the  secretion  happens  to  be  rich  in 
fibrine,  and  hence  possessed  of  a  marked  tendency  to  coagulate 
on  the  surface  of  the  conjunctiva. 

Causes. — Contagion,  Epidemic. 

Treatment. — Iced  compresses,  or  Leiter's  tubes,  to  the  eyelids 
during  the  croupous  stage,  with  antiseptic  cleansing  of  the  con- 
junctival sac  (Sol.  Hydrarg.  Perchlor.  1  in  5000,  or  Sol.  Acid 
Borac.  4  per  cent.).  No  caustic  should  be  used  in  this  stage,  as 
it  is  apt  to  produce  corneal  changes.  Sulphate  of  quinine 
sprinkled  on  the  conjunctiva  is  praised  by  some  surgeons  as  a 
useful  application  at  this  period.  When  the  false  membrane 
ceases  to  be  formed  a  slight  blennorrhcea  comes  on,  and  this  is 
to  be  treated  with  nitrate  of  silver  applications  in  the  usual  way. 

Diphtheritic  Conjunctivitis. — There  is  no  more  serious  ocular 
disease  than  this,  for  it  may  destroy  the  eye  in  twenty-four  hours, 
while  in  severe  cases  treatment  is  almost  powerless.  Fortu- 
nately, it  is  almost  unknown  in  these  countries,  while  in  Berlin 
it  used  to  be  so  frequent  that  von  Graefe  set  apart  two  wards  for 
it  in  his  hospital,  which  were  under  my  care  as  his  assistant. 
It  is  now  a  much  less  common  disease  there,  owing  probably  to 
the  improved  hygiene  of  the  city. 

The    subjective    symptoms   of  its   initial   stage    are   similar, 


THE   CONJUNCTIVA.  109 

although  severer,  especially  iu  the  matter  of  pain,  to  those  of 
blennorrhoeic  conjunctivitis.  The  objective  symptoms  differ  from 
those  of  blenuorrhoea  in  that  the  lids  are  excessively  stiff,  owing 
to  plastic  infiltration  of  the  subepithelial  and  deeper  layers  of 
the  conjunctiva,  while  the  surface  of  the  mucous  membrane  is 
smooth  and  of  a  grayish  or  pale-buff  color.  If  an  attempt  be 
made  to  peel  off  some  of  the  superficial  exudation  the  surface 
underneath  will  be  found  of  the  same  gray  color,  not  red  and 
vascular,  as  in  croupous  conjunctivitis.  This  stage  of  infiltration 
lasts  from  six  to  ten  days,  and  constitutes  the  period  of  greatest 
peril  to  the  eye ;  for,  while  it  lasts,  the  nutrition  of  the  cornea 
must  suffer,  and  sloughing  of  that  organ  is  extremely  apt  to 
take  place.  Toward  the  close  of  the  first  stage  the  fibrinous 
infiltration  is  eliminated  from  the  eyelids,  and  the  conjunctiva 
gradually  assumes  a  red  and  succulent  appearance,  and  at  the 
same  time  a  purulent  discharge  is  established.  This  constitutes 
the  second  or  blennorrhoeic  stage.  A  third  stage  is  formed  by 
cicatricial  alterations  in  the  mucous  membrane,  which  often  lead 
to  symblepharon  or  to  xerophthalmos ;  so  that,  even  if  the  eye 
escape  corneal  dangers  in  the  first  and  second  stages,  others 
almost  as  serious  may  await  it  in  the  final  stage. 

Corneal  complications  are  most  likely  to  occur  iu  the  first 
stage,  and  are  then  also  most  likely  to  prove  destructive  to  the 
eye.  The  earlier  they  appear  the  more  dangerous  are  they.  If 
the  blennorrhoeic  stage  come  on  before  corneal  complications 
appear,  or  even  before  an  ulcer  contracted  in  the  first  stage  has 
advanced  far,  they  are  more  easily  managed. 

Causes. — It  is  difficult  to  assign  a  cause  for  this  disease,  which 
chiefly  attacks  children.  It  is  frequently  epidemic,  is  extremely 
infectious,  and,  although  similar  in  its  nature,  is  rarely,  if  ever, 
found  in  connection  with  an  attack  of  diphtheritis  of  the  fauces. 

Treatment. — In  the  first  stage,  frequent  warm  fomentations, 
with  antiseptic  cleansing,  are  the  only  local  measures  admissible. 
No  caustic  or  astringent  application  should  be  used.  Internally, 
the  patient  should  be  treated  with  iron  and  quinine  and  generous 
diet.     In  the  second,  or  blennorrhoeic  stage,  careful  caustic  appli- 


110  DISEASES   OF   THE   EYE. 

cations  are  to  be  used.  Corneal  ulcers  must  be  dealt  with  when- 
ever they  arise,  in  the  same  way  as  though  the  case  were  one  of 
blennorrhceic  conjunctivitis.  When  the  purulent  discharge  ceases, 
solutions  of  soda,  milk,  or  glycerine  may  be  prescribed  as  lotions 
for  the  conjunctiva,  to  arrest,  if  possible,  the  xerophthalmos. 

Conjunctival  Complication  of  Smallpox. — Of  this  I  have,  for- 
tunately, too  little  experience  to  enable  me  to  speak  authorita- 
tively. The  following  embodies  the  views  of  the  late  Professor 
Horner,*  who  studied  the  subject  during  an  epidemic  in  1871. 
A  good  deal  of  uncertainty  prevailed  previously,  for  the  initial 
stages  of  the  eye  affection  were  not  carefully  observed  by 
physicians,  owing  to  the  swelling  of  the  eyelids,  while  the 
ophthalmologist  saw  only  the  results  of  the  process  in  the  period 
of  convalescence. 

Smallpox  pustules  on  the  cornea  are,  Horner  believed, 
extremely  rare;  indeed,  he  saw  but  one  such  case.  The  most 
frequent,  and  most  serious,  mode  of  attack  consists  in  a  grayish- 
yellow  infiltration  in  the  conjunctiva  close  to  the  lower  margin 
of  the  cornea,  not  extending  to  the  fornix  conjunctivae,  nor  far 
along  the  inner  or  outer  margin  of  the  cornea.  It  occurs  in  the 
eruptive  stage,  and  is  to  be  regarded  clinically  as  a  variola 
pustule.  This  infiltration  or  pustule  gives  rise  to  a  corneal  affec- 
tion, as  does  a  solitary  marginal  phlycteuula,  either  in  the  form 
of  a  marginal  ulcer,  or  as  a  deep  purulent  infiltration,  ulcerating, 
perforating,  leading  to  staphyloma,  purulent  irido-choroiditis,  and 
panophthalmitis  ;  results  which  are  often  first  observed  long 
after  the  primary  conjunctival  affection  has  disappeared. 

Horner  believed  that  the  germ  of  the  conjunctival  infiltration 
makes  its  way  between  the  eyelids,  and  that  the  constancy  of  the 
position  of  the  infiltration  is  accounted  for  by  this  theory,  that 
part  of  the  conjunctiva,  with  closed  eyelids  and  eyeball  con- 
sequently rotated  upward,  being  the  most  exposed  to  particles 
entering. 

Treatment. — On  this  ground  he  recommended  the  prophylactic 

*Loc.  ciL,  p.  297. 


THE   CONJUNCTIVA.  Ill 

use  of  boracic  acid  ointment  on  lint  applied  over  the  eyelids.  If 
a  conjunctival  pustule  have  already  formed,  without  any,  or  only 
commencing,  corneal  affection,  he  would  destroy  the  pustule 
with  fresh  chlorine  water,  or  with  mitigated  lapis  carefully 
neutralized.  Corneal  complications  are  treated  as  in  blennorrhoea 
of  the  conjunctiva  or  diphtheritis. 

The  frequency  with  which  the  eyes  become  affected  varies  in 
different  epidemics. 

As  true  post-variolous  eye-affections,  Horner  recognized  diffuse 
keratitis,  iritis,  and  iridocyclitis,  with  opacities  in  the  vitreous 
humor  and  glaucoma.  In  the  hemorrhagic  form  of  the  disease, 
hemorrhages  in  the  conjunctiva  and  retina;  and,  where  pyaemic 
poisoning  comes  on,  septic  affections  of  the  choroid  and  the  retina 
take  place. 

Amyloid  Degeneration. — This  rare  disease  attacks  chiefly  the 
palpebral  conjunctiva,  but  is  also  seen  in  the  bulbar  portion.  It 
causes  great  tumefaction  of  the  affected  lid,  without  any  inflam- 
matory symptoms.  The  eyelid  can  be  but  partially  elevated, 
and  is  often  so  stiff  and  hard  that  it  can  be  everted  only  with 
difficulty.  The  conjunctiva  has  the  appearance  of  white  wax. 
The  disease  ultimately  extends  to  the  tarsus,  but  is  a  strictly 
localized  process  and  not  associated  with  amyloid  disease  in  any 
other  part  of  the  system.  It  sometimes  seems  to  be  developed 
from  granular  ophthalmia,  but  occurs  also  as  a  primary  disease. 
The  positive  diagnosis  can  be  made  by  submitting  a  small  portion 
of  the  diseased  conjunctiva  to  the  iodine  test. 

Hyaline  Degeneration  of  the  conjunctiva  has  also  been  ob- 
served. It  cannot  clinically  be  distinguished  from  Amyloid 
Degeneration,  and  is  really  an  early  stage  of  the  latter  condition. 

Treatment  consists  in  the  removal  of  the  diseased  parts,  by  the 
knife  and  scraping,  so  far  as  may  be  possible. 

Tubercular  Disease  of  the  Conjunctiva. — This  is  an  extremely 
rare  disease.  It  commences  in  the  palpebral  conjunctiva  of  the 
upper  lid  usually,  very  rarely  in  the  bulbar  conjunctiva,  as  small, 
round,  yellowish-gray  nodules,  which  soon  ulcerate.  The  margins 
of  these  ulcers  are  well  defined,  and  their  floors  of  a  yellowish 


112  DISEASES   OF   THE   EYE. 

lardaceous  appearance,  or  covered  with  grayish-red  granulations. 
The  surrounding  conjunctiva  is  swollen,  and,  if  the  palpebral 
conjunctiva  be  much  involved,  the  lid  becomes  enlarged  in  every 
dimension,  and  the  ulcerative  process  may  soon  destroy  part  of 
the  lid.  It  may  also  extend  to  the  bulbar  conjunctiva,  and  the 
cornea  may  become  covered  with  pannus.  The  pre-auricular 
and  submaxillary  glands  usually  become  enlarged.  The  positive 
diagnosis  of  the  nature  of  the  disease  should  be  made  by  an 
examination  of  portions  of  the  floor  of  the  ulcer  for  the  charac- 
teristic tubercle  bacillus,  which  will  distinguish  this  from  second- 
ary syphilitic  ulceration  of  the  conjunctiva,  between  which  and 
the  tubercular  ulceration  there  is  sometimes  a  resemblance. 
Tubercular  conjunctival  disease  is  usually  unattended  by  pain, 
or  there  is  only  a  slight  burning  sensation  ;  but,  again,  when  the 
ulceration  is  extensive,  severe  pain  may  set  in. 

This  is  a  very  chronic  disease,  its  progress  sometimes  extend- 
ing over  many  years,  and  it  is  rarely  met  with  except  in  youth. 
Some  of  those  whose  eyes  are  attacked  are  already  the  subjects 
of  tuberculosis  in  other  organs,  but  very  many  of  them  are  per- 
fectly healthy  in  that  respect.  In  fact,  we  have  reason  to  believe 
(Valude,  Leber)  that  tuberculosis  of  the  conjunctiva  is  much 
more  often  a  primary  disease,  the  result  of  an  ectogenic  infection, 
even  in  cases  where  already  tuberculosis  exists  elsewhere,  than  of 
infection  occurring  through  the  blood.  Tubercle  bacilli  intro- 
duced into  the  normal  conjunctival  sac  have,  it  is  true,  been 
found  to  be  harmless,  for  the  intact  epithelium  offers  an  insuper- 
able obstacle  to  their  entrance  into  the  tissue.  But  a  superficial 
loss  of  substance  of  the  conjunctiva  is  sufficient  to  allow  of  its 
inoculation  with  the  bacilli,  and  then  the  disease  becomes  estab- 
lished. The  frequent  lodgment  of  foreign  bodies  under  the 
upper  lid  explains  why  this  is  the  most  common  place  for  the 
disease  to  begin  in.  But,  although  conjunctival  tubercular  dis- 
ease is  not  often  secondary  to  tubercular  disease  in  other  parts  of 
the  system,  yet  it  is  itself  liable  to  be  the  starting-point  of  gen- 
eral tuberculosis. 

Treatment. — The  fact  last  mentioned  makes  it  most  important, 


THE   CONJUNCTIVA.  113 

in  cases  of  primary  tubercular  disease  of  the  conjunctiva,  to 
thoroughly  eradicate  the  disease,  so  as  to  avert  an  infection  of 
other  organs,  and  this  can  often  be  effected.  If  the  ulcers  be  not 
already  too  extensive  they  must  be  scraped,  and  the  actual 
cautery  freely  applied  to  them  ;  and,  where  the  disease  has 
already  spread  to  the  cornea,  sclerotic,  iris,  or  choroid,  enuclea- 
tion of  the  eyeball  is  instantly  called  for. 

Lupus  of  the  conjunctiva  usually  occurs  as  an  extension  of  the 
disease  from  the  surrounding  skin.  It  is  seen  as  a  patch  or 
patches  of  ulceration,  covered  with  small,  dark-red  protuber- 
ances or  granulations,  chiefly  on  the  palpebral  conjunctiva,  which 
bleed  easily  on  being  touched. 

Like  lupus  of  the  skin,  these  ulcerations  undergo  spontaneous 
healing  and  cicatrization  in  one  place  (unlike  tubercular  ulcera- 
tion in  that  respect),  while  they  are  still  creeping  over  the  sur- 
face in  another  direction.  But  we  now  know  that  lupus,  when- 
ever it  occurs,  is  really  a  tubercular  disease,  and  that  the  two 
forms  differ  only  in  their  clinical  appearances. 

The  Treatment  is  scraping  with  a  sharp  spoon,  and  the  appli- 
cation of  the  actual  cautery. 

Pemphigus  of  the  Conjunctiva. — This  is  another  rare  disease. 
It  has  been  seen  in  connection  with  pemphigus  vulgaris  of  other 
parts  of  the  body,  but  it  also  occurs  as  an  independent  disease. 
It  is  attended  by  attacks  of  much  pain,  photophobia,  and  lach- 
rymation,  and  the  conjunctiva,  at  each  place  where  subconjunc- 
tival exudation  of  serum  has  been  situated,  undergoes  degener- 
ation and  cicatricial  contraction.  Such  attacks  succeed  each 
other  at  shorter  or  longer  intervals,  for  weeks,  months,  or  years, 
until  finally  the  entire  conjunctiva  of  each  eye  may  have  become 
destroyed  and  the  eyelids  are  adherent  to  the  eyeball.  The  cor- 
nea gradually  becomes  completely  opaque,  or,  having  ulcerated, 
becomes  staphylomatous.  In  the  course  of  the  disease  the  eye- 
lashes are  apt  to  become  turned  in  on  the  eyeball,  or  even  entro- 
pion may  form;  and  these  conditions  aggravate  the  suffering  of 
the  patient. 

The  foregoing  is  a  description  of  a  severe  case.  In  less  severe 
10 


114 


DISEASES   OF   THE   EYE. 


cases  the  conjunctiva  may  not  be  completely  destroyed,  and  the 
cornea  may  not  be  affected. 

The  formation  of  a  true  bulla  hardly  ever  occurs,  for  the  con- 
junctival epithelium  is  so  delicate  that  it  cannot  be  disturbed  in 
this  way  by  the  serous  exudation  beneath  it,  but  rather  breaks 
down  at  once.  Consequently  the  conjunctival  surface  is  found, 
in  these  cases,  to  be  covered  by  what  looks  like  a  membranous 
deposit,  upon  removal  of  which  a  raw  surface  is  exposed  ;  and  these 
appearances  have  led  to  the  mistaken  diagnoses  of  croupous,  or 
diphtheritic,  conjunctivitis. 

Treatment  is  helpless  in  respect  of  arresting  the  progress  of  the 
disease  or  of  restoring  sight  when  lost  in  consequence  of  it.  The 
most  one  can  do  is  to  relieve  the  distressing  symptoms  by  emol- 
lients to  the  conjunctiva,  and  by  the  use  of  closely-fitting  goggles, 

to   protect  from   wind,  dust, 
^]^-  ^^'  and  sun.     Internally,  arsenic 

is  indicated. 

Xerosis,  or  Xerophthalmos, 
is  a  dry,  lustreless  condition 
of  the  conjunctiva,  associated, 
in  the  severer  forms,  with 
shrinking  of  the  membrane. 
There  are  two  forms  of  the 
affection  —  the  parenchyma- 
tous and  the  epithelial. 

In  Parenchymatous  Xer- 
ophthalmos there  is  a  more  or 
less  extensive  cicatricial  de- 
generation of  the  conjunctiva, 
dependent  upon  changes  in  its 
deeper  layers,  while  its  surface 
and  thatof  the  cornea  become 
dry  and  the  latter  becomes 
opaque,  and  the  eye  conse- 
quently sightless.  The  conjunctiva  shrinks  so  completely,  in 
many  of  these  cases,  that  both  lids  are  found  adherent  in  their 


<fi^> 'v- ' 


THE    CONJUNCTIVA.  115 

whole  extent  to  the  eyeball,  which  is  exposed  merely  at  the 
palpebral  fissure,  where  the  opaque  and  lustreless  cornea  is  to  be 
seen.  From  what  remains  of  the  conjunctiva,  scales,  composed 
of  dry  epithelium,  fat,  etc.,  peel  away.  The  motions  of  the 
eyeball  are  restricted  in  proportion  to  the  extent  of  the  con- 
junctival degeneration.     There  is  no  cure  for  this  condition. 

Fig.  53  represents  a  case  of  xerophthalmos,  the  result  of  pem- 
phigus, which  was  under  my  care  in  the  National  Eye  and  Ear 
Infirmary.  Here  the  eyelids  were  not  wholly  adherent  to  the 
eyeball,  and  the  cornea  remained  clear. 

The  Causes  of  parenchymatous  xerosis  of  the  conjunctiva  are: 
Granular  ophthalmia,  diphtheritic  ophthalmia,  pemphigus,  and 
the  condition  is  said  to  be  very  occasionally  seen  as  a  primary  dis- 
ease, described  as  essential  shrinking  of  the  conjunctiva.  Many 
observers  altogether  deny  the  existence  of  the  primary  aflfection, 
and  maintain  that  the  cases  described  as  of  that  nature  are 
merely  the  results  of  pemphigus,  and  I  am  inclined  to  agree  with 
this  view. 

Treatment. — As  cure  is  impossible  in  this  form  of  xerophthal- 
mos, the  only  indication  is  to  afford  relief,  so  far  as  it  can  be 
done,  from  the  distressing  sensations  of  dryness  of  the  eyes 
which  are  complained  of  The  best  applications  are  milk, 
glycerine,  olive  oil,  and  weak  alkaline  solutions,  and  the  eyes 
should  be  protected  from  all  irritating  influences  by  protection 
goggles. 

Epithelial  Xerosis  of  the  conjunctiva  is  confined  to  the 
epithelium  of  that  part  of  the  conjunctiva  which  covers  the  ex- 
posed portion  of  the  sclerotic  in  the  palpebral  opening.  It  there 
becomes  dry  and  dull  and  covered  with  small  white  spots ;  while 
the  whole  bulbar  conjunctiva  is  loose  and  easily  thrown  into 
folds  by  motions  of  the  eyeball,  and  there  may  be  a  good  deal  of 
secretion.  This  form  of  xerophthalmos  often  occurs  in  epi- 
demics, but  also  sporadically,  accompanied,  oddly  enough,  by 
night-blindness  (the  light-sense  unimpaired)  and  contraction  of 
the  field  of  vision.  The  combined  condition  has  been  noticed 
chiefly  in  persons  of  debilitated  constitution,  who  have  been  ex- 


116  DISEASES   OF   THE   EYE. 

posed  to  strong  glares  of  light,  and  is  said  to  have  appeared  in 
epidemics,  under  these  conditions,  in  foreign  prisons  and 
barracks. 

Treatment  by  rest,  protection  from  glare  of  light,  nutritious 
diet,  and  tonics,  invariably  restores  the  eyes  to  their  normal 
functions. 

Again,  epithelial  xerosis  occurs  in  very  young  children  in  con- 
nection with  a  destructive  ulceration  of  the  cornea  (see  Infantile 
Ulceration  of  the  Cornea  with  Xerosis  of  the  Conjunctiva,  Chap. 
VIII). 

Pterygium  {-ripo^,  a  iving). — This  is  a  vascularized  thicken- 
ing of  the  conjunctiva,  triangular  in  shape,  situated  most  usually 
to  the  inside  of  the  cornea,  sometimes  to  its  outer  side,  and  rarely 
either  above  or  below  it.  The  apex  of  the  triangle,  the  "  head  " 
of  the  pterygium,  is  on  the  cornea ;  and  its  base,  the  "  body," 
at  the  semi-lunar  fold.  The  "  neck  "  of  the  pterygium  is  that 
part  of  it  at  the  margin  of  the  cornea.  There  is  frequently,  but 
not  always,  a  tendency  of  the  growth  to  advance  into  the  cornea, 
of  which  it  seldom  reaches  the  centre,  and  still  more  rarely 
extends  quite  across  it. 

In  its  early  growth  the  pterygium  is  rather  thick  and  succu- 
lent-looking and  very  vascular.  But  finally  it  ceases  to  grow, 
and  then  becomes  thin  and  pale,  and  this  is  its  retrogressive 
stage ;  yet  it  never  entirely  disappears.  Sight  is  not  affected, 
unless  the  pterygium  extend  over  the  pupillary  region  of  the 
cornea.  A  limitation  of  the  motion  of  the  eye  to  the  other  side, 
and  consequent  diplopia,  is  sometimes  caused  by  a  pterygium, 
but,  for  the  most  part,  the  disfigurement  alone  is  what  brings 
these  cases  to  the  surgeon. 

Cause. — The  starting  point  of  a  pterygium  is  often  an  ulcer  at 
the  margin  of  the  cornea,  which  in  healing  catches  a  morsel  of 
the  limbus  conjunctivae  and  draws  it  toward  the  cicatrix,  throw- 
ing the  mucous  membrane  into  a  triangular  fold.  The  ulcer 
then  forms  anew  in  the  cornea  immediately  inside  the  cicatrix, 
and,  in  healing,  the  point  of  conjunctiva  is  drawn  into  it  again, 
and  is  carried  a  little  further  into  the  cornea,  and  so  on.     The 


THE   CONJUNCTIVA.  117 

hollow  lying  between  a  Pinguecula  (see  below)  and  the  margin 
of  the  cornea  is  apt  to  lodge  small  foreign  bodies,  which  cause 
shallow  marginal  ulcers,  and  these,  in  healing,  draw  the  Pingue- 
cula over  on  the  cornea.  A  marginal  ulcer  in  phlyctenular 
keratitis  or  in  acute  blennorrhoea  may  serve  the  same  end.  The 
only  objection  to  this  theory  of  the  causation  of  pterygium  is 
that  an  ulcer  is  not  always  to  be  found  at  the  head  of  the  growth. 

Pterygium  is  a  rare  affection  in  this  country,  but  is  more  com- 
mon in  countries  or  localities  where  the  air  is  filled  with  fine 
sand,  or  other  minute  particles. 

Treatment. — Unless  the  pterygium  be  very  thick,  and  have 
invaded  the  cornea  to  some  extent,  or  be  progressing  over  the 
cornea,  it  is  well  to  let  it  alone  ;  the  more  so  as,  by  removing  it, 
a  quite  normal  appearance  is  not  given  to  the  eye,  for  a  mark 
is  necessarily  left  both  on  cornea  and  conjunctiva.  If  it  be  pro- 
gressive, or  very  disfiguring,  it  should  be  removed,  other  pro- 
posed modes  of  dealing  with  it  being  futile.  This  may  be  effected 
either  by  ligature  or  excision. 

In  the  method  by  ligature,  a  strong  silk  suture  is  passed  through 
two  needles.  The  pterygium  being  raised  with  a  forceps  close 
to  the  cornea,  one  needle  is  passed  under  it  here,  and  the  other 
needle  in  the  same  way  close  to  its  base,  the  ligature  being 
drawn  half  way  through.  The  thread  is  cut  close  behind  each 
needle,  thus  forming  three  ligatures,  which  are  respectively  tied 
tight.     In  four  or  five  days  the  pterygium  comes  away. 

For  excision,  the  apex  is  seized  with  a  forceps  and  dissected  off, 
either  with  a  scissors  or  fine  scalpel,  care  being  taken  not  to 
injure  the  true  cornea.  The  dissection  is  continued  toward  the 
base  of  the  pterygium,  where  it  is  finished  with  two  convergent 
incisions  meeting  at  the  base.  The  mucous  membrane  in  the 
neighborhood  of  the  base  is  separated  up  somewhat  from  the 
sclerotic,  and  the  margins  of  the  conjunctival  wound  are  then 
carefully  brought  together  with  sutures. 

Pinguecula  (pinguis,/aO  is  the  name  given  to  a  small,  yellow- 
ish elevation  in  the  conjunctiva  near  the  margin  of  the  cornea, 
usually  at  its  inner  side,  more  rarely  at  its  temporal  margin,  but 


118 


DISEASES   OF   THE    EYE. 


sometimes  in  each  place.  It  contains,  notwithstanding  its  name, 
no  fat,  but  is  composed  of  connective  tissue  and  elastic  fibres. 
It  is  supposed  to  be  due  to  the  irritation  caused  by  small  foreign 
bodies.  It  rarely  grows  to  a  large  size,  and  requires  no  treat- 
ment, unless  it  become  very  disfiguring,  when  it  may  be  removed 
with  forceps  and  scissors. 

Subconjunctival  Ecchymosis. — The  rupture  of  a  small  sub- 
conjunctival vessel  in  the  bulbar  conjunctiva,  without  conjunc- 
tivitis, is  of  frequent  occurrence.  It  suddenly  gives  a  more  or 
less  extensive  purple  hue  to  the  "  white  of  the  eye,"  causing  the 
patient  much  concern.  It  is  common  enough  in  old  people,  but 
may  occur  in  the  young,  and  even  in  children  from  severe  strain- 
ing, as  in  whooping  cough,  vomiting,  or  raising  heavy  weights. 
It  is  occasionally  significant  of  diabetes.  It  also  occurs  some- 
times during  epileptic  fits,  and  profuse  subconjunctival  hemor- 
rhage is  occasionally  found  in  cases  of  fracture  of  the  base  of  the 
skull,  having  made  its  way  along  the  floor  of  the  orbit.  It  is 
of  no  importance,  so  far  as  the  integrity  of  the  eye  is  concerned 
Treatment. — None  is  required,  the  extravasated  blood  gradu- 
ally becoming  absorbed. 

Polypus  of  the  conjunctiva,  for  which  it  is  difiacult  to  assign  a 
cause,  is  sometimes  seen.  It  is  generally  small,  in  connection 
with  the  semi-lunar  fold  or  caruncle,  and  can  readily  be  removed 

with   the  scissors.     Granula- 
FiG.  54.  tions    occurring    after    teno- 

tomy for  strabismus  are  some- 
times, and  incorrectly,  called 
polypi. 

Dermoid  Tumors. — These 
are  pale  yellow  in  color, 
and  in  size  from  that  of  a 
split  pea  to  that  of  a  cherry. 
They  are  smooth  on  the  sur- 
face, and  sometimes  have  fine 
hairs,  and  sit  usually  at  the 
outer  and  lower  margin  of  the  cornea,  but  Fig.  54  was  drawn 


THE   CONJUNCTIVA.  119 

from  a  case  on  which  I  operated,  where  the  dermoid  was  situated 
on  the  inner  side  of  the  cornea,  and  not  at  the  most  usual  seat 
extending  over  somewhat  on  the  latter.  In  structure  they 
resemble  that  of  the  skin.  They  are  congenital  tumors,  sup- 
posed to  be  due  to  an  arrest  in  development,  but  they  often 
have  a  tendency  to  extend  over  the  cornea.  If  this  tendency 
be  present,  the  tumor  must  be  removed  by  dissecting  it  off  the 
cornea,  care  being  taken  not  to  go  into  the  deep  layers  of  the 
latter. 

Syphilitic  Disease  of  the  Conjunctiva  occurs  both  as  primary 
and  as  secondary  disease.  It  will  be  treated  of  in  Chap.  VI,  on 
Diseases  of  the  Eyelids. 

Papilloma,  or  Papillary  Fibroma. — This  is  a  non-malignant 
growth  which  may  spring  from  any  part  of  the  conjunctival  sac. 
It  appears  in  the  beginning  as  a  small,  round,  red  knob.  The 
papillomata  growing  from  the  tarsal  conjunctiva  and  from  the 
semilunar  fold  frequently  take  on  a  cauliflower  appearance,  while 
on  the  bulbar  conjunctiva  and  in  the  fornix  the  growths  are  liable 
to  be  pedunculated,  with  a  papillary  surface.  The  limbus  of  the 
conjunctiva  is  a  favorite  seat  for  a  papilloma,  and  in  the  early 
stage  it  may  be  impossible  to  distinguish  it  from  an  epithelioma. 
But  if  the  case  come  under  observation  at  a  later  stage,  when  the 
growth  has  overlapped  the  cornea,  this  difficulty  does  not  arise, 
for  the  papilloma  merely  lies  on  the  cornea,  and  can  be  lifted 
freely  off  it  with  a  probe,  while  the  epithelioma  infiltrates  the 
corneal  tissue. 

Treatment. — Thorough  removal  with  knife  or  scissors,  and 
actual  cautery,  as  otherwise  the  growth  is  liable  to  recur. 

Epithelioma  is  not  common  as  a  primary  disease  of  the  con- 
junctiva. When  it  is  so  found,  it  is  seen  as  a  little,  nou-pigmented 
tumor  growing  from  the  limbus  of  the  conjunctiva,  surrounded  by 
vascularization,  and  may  in  this  stage  be  mistaken  for  a  phlycten- 
ula — of  which,  however,  the  margins  are  not  so  steep — or  for  a 
papilloma  (vide sujjra).  As  the  tumor  increases  in  size,  it  becomes 
lobulated   and    ulcerates,  and    soon  attacks  the   cornea,  giving 


120  DISEASES   OF   THE   EYE. 

rise  on  the  latter  to  an  appearance  very  like  pannus.  The 
neighboring  lymphatic  glands  become  enlarged. 

Sarcoma,  too,  is  rare,  and  also  takes  its  origin  in  the  limbus 
conjunctivae.  It  is  usually  a  pigmented  tumor,  a  melanosar- 
coma.  It  does  not  attack  the  cornea  so  readily  as  the  epithelio- 
matous  growths,  although  it  often  overlaps  the  surface  of  the 
cornea.  In  its  later  stages  this  tumor  grows  to  an  enormous  size. 
That  these  sarcomata  are  pigmented  is  explained  by  the  fact  that 
the  limbus  contains  pigment,  although  usually  so  slight  in  amount 
as  not  to  be  visible  to  the  naked  eye. 

Treatment — Both  epithelioma  and  sarcoma  of  the  conjunctiva 
demand  prompt  operative  removal,  in  order  to  prevent  an  exten- 
sion of  the  growth  to  the  rest  of  the  eye,  if  the  case  be  seen  early, 
as  well  as  to  avert  metastases  to  other  organs.  The  knife  and 
actual  cautery  may  save  the  eye  and  the  life  in  the  early  stages  ; 
but,  later,  removal  of  the  whole  eye  is  often  called  for. 

Simple  Cysts  of  the  conjunctiva  are  very  rare.  They  appear 
as  clear,  spherical  protuberances  of  about  the  size  of  a  pea,  seated 
usually  on  the  bulbar  conjunctiva.  The  walls  of  the  cysts  contain 
but  few  vessels,  are  thin,  and  almost  transparent,  while  for  con- 
tents they  have  a  clear,  limpid  fluid.  These  cysts  cannot,  as  a  rule, 
be  moved  from  their  position,  because  they  are  adherent  to  the 
conjunctiva,  which,  indeed,  takes  part  in  the  formation  of  their 
walls.     They  are,  very  probably,  dilated  lymphatic  vessels. 

These  simple  cysts  are  most  commonly  congenital,  but  they  may 
begin  to  be  developed  during  life. 

Treatment. — The  cyst  may  be  dissected  out,  or  it  may  be  suffi- 
cient to  abscise  its  anterior  wall. 

Subconjunctival  Cysticercus  is  a  little  more  common  than  simple 
cyst  of  the  conjunctiva,  and  yet  only  forty-six  examples  of  it  have 
been  placed  on  record.  Of  these  the  most  recent  is  Dr.  Louis 
Werner's  case.* 

*  Tran.  Ophthal.  Soc,  ix,  p.  74.  The  literature  of  the  subject  is  there 
fully  given. 


THE    CONJUNCTIVA.  121 

Cysticercus  is  distinguished  from  simple  cyst  by  its  free  mobil- 
ity under  the  coDJuiictiva,  to  which  it  is  not  attached;  by  its 
thicker  and  more  vascular  walls;  and,  above  all,  by  the 
presence  of  a  round,  white,  opaque  spot  on  the  anterior  surface, 
first  pointed  out  by  Sichel  and  looked  on  by  him  as  pathognomonic 
of  a  cysticercus.  This  spot  indicates  the  position  of  the  receptacu- 
lum;  and  occasionally,  wdien  this  comes  to  be  placed  on  the 
posterior  surface  of  the  cyst,  it  may  be  difficult  or  impossible 
to  make  the  diagnosis  with  certainty. 

Treatment — The  cyst  may  be  pushed  to  one  side  under  the 
conjunctiva,  an  incision  made  in  the  latter,  the  cyst  then  pushed 
back  again,  and  out  through  the  opening. 

Lithiasis  consists  in  the  calcification  of  the  secretion  of  the 
Meibomian  glands,  which  are  seen  as  little,  brilliantly  white  spots 
not  larger  than  a  pin's  head,  in  the  conjunctiva.  There 
may  be  one  only,  or  v€ry  many.  These  concretions  often  give 
rise  to  much  conjunctival  irritation;  and,  if  they  protrude  over 
the  surface  of  the  conjunctiva,  may  injure  the  cornea.  Each  one 
— the  eye  having  been  cocainized — must  be  separately  removed 
by  a  needle,  with  which  first  an  incision  has  been  made  into  the 
conjunctiva  over  the  concretion. 

Injuries  of  the  Conjunctiva. — Foreign  bodies  frequently  make 
their  way  into  the  conjunctival  sac  and  cause  much  pain,  espe- 
cially if  they  get  under  the  upper  lid,  by  reason,  chiefly,  of  their 
coming  in  contact  with  the  corneal  surface  during  motions  of  the 
lid  and  of  the  eye.  If  the  foreign  body  be  under  the  lower  lid,  it 
will  be  easily  found  on  drawing  down  the  latter,  and,  provided  it 
be  not  actually  embedded  in  the  mucous  membrane,  it  is  easily 
removed  with  a  camel's  hair  pencil  or  with  the  corner  of  a  soft 
pocket-handkerchief  But  if  the  foreign  body  be  under  the  upper 
lid,  it  is  necessary  to  evert  the  latter  before  it  is  reached.  Should 
the  foreign  body  be  embedded  in  the  conjunctiva,  it  must  be 
pricked  out  of  its  position  with  the  point  of  a  needle  or  other 
suitable  instrument,  and  the  little  proceeding  will  be  made  easier, 
11 


122  DISEASES   OP   THE    EYE. 

both  for  patient  and  surgeon,  by  the  instillation  of  a  few  drops  of 
solution  of  cocaine  (two  per  cent.)  into  the  eye.* 

The  conjunctiva  is  frequently  injured  in  severe  wounds  of  the 
eyelids  or  eyeball.  The  interest  and  treatment  centre,  here, 
chiefly  on  the  other  more  important  parts  which  have  been  injured. 
A  tear  or  wound  of  the  conjunctiva  (usually  of  the  bulbar  por- 
tion), when  it  occasionally  occurs  without  injury  to  other  parts,  is 
in  general  of  very  slight  moment.  If  the  wound  be  extensive,  its 
edges  should  be  drawn  together  with  a  few  points  of  suture;  but, 
otherwise,  healing  will  take  place  with  the  aid  simply  of  a  bandage 
to  keep  the  eye  closed  for  a  few  days. 

The  common  form  of  injury,  which  may  involve  the  conjunctiva 
alone,  is  a  burn  by  acid  or  lime.  In  the  case  of  a  strong  acid 
getting  into  the  eye,  if  the  patient  be  seen  immediately  after  the 
occurrence,  the  whole  conjunctival  sac  should  be  well  washed  out 
with  an  alkaline  solution  ;  while,  in  the  case  of  lime,  a  weak  solu- 
tion of  a  mineral  acid  is  indicated  for  the  purpose.  Cocaine  may 
be  employed  to  relieve  the  pain.  Subsequently,  protection  of  the 
eye,  with  the  use  of  olive  or  castor  oil  dropped  into  it,  will  best  pro- 
mote the  healing  process. 

In  the  case  of  a  severe  burn  of  the  conjunctiva,  the  resulting 
cicatrix  is  liable  to  produce  a  more  or  less  extensive  union  of  the 
eyelid  to  the  eyeball  (Symblepharon),  which  often  interferes  with 
the  motion  of  the  latter,  or  even  with  vision,  if  the  cornea  be  ob- 
scured. No  measures  taken  during  the  healing  process  can  pre- 
vent symblepharon  if  the  degree  of  the  burn  be  such  as  to  bring  it 
about.  The  relief  of  symblepharon  by  operation  will  be  dealt 
with  in  Chap.  VI,  on  Diseases  of  the  Eyelids. 

*  The  continuous,  or  frequently  recurring,  sensation  of  a  foreign  body 
in  the  conjunctival  sac,  while  nothing  of  the  kind,  nor  any  hyperaemia, 
is  present,  is  sometimes  a  premonitory  sign  of  mental  disease. 


CHAPTEK  V. 

PHLYCTENULAR,  OR  STRUMOUS,  CONJUNC- 
TIVITIS AND  KERATITIS." 

Both  from  a  clinical  and  nosological  point  of  view,  it  would 
be  incorrect  to  divide  this  affection  into  two,  under  the  heads  of 
Diseases  of  the  Conjunctiva  and  Diseases  of  the  Cornea;  and, 
therefore,  I  treat  of  it  here  as  one  disease ;  and,  being  a  very  im- 
portant disease,  I  devote  a  special  chapter  to  it.  It  is  important 
because  it  is  excessively  common,  and  because  it  is  capable  of 
causing  considerable  damage  to  sight.  Moreover,  even  when  it 
occurs  on  the  cornea,  it  should  probably  be  regarded  as  a  con- 
junctival disease,  for  the  corneal  layer,  which  it  primarily 
attacks,  is  the  epithelium,  and  this — if  not  also,  as  some  authors 
state,  Bowman's  membrane  and  the  anterior  layers  of  the  true 
cornea — as  we  know  from  the  foetal  development  of  the  mem- 
brane, is  a  continuation  of  the  conjunctiva,  in  a  modified  form, 
over  the  cornea. t 

Hornert  termed  it  Eczema  of  the  Conjunctiva  and  Cornea. 
It  is  characterized  by  the  eruption  of  phlyctenule  (cr/'jz7ar>a,  a 
vesicle,  or  pustule)  on  the  conjunctiva  bulbi  (but  never  on  the 
palpebral  conjunctiva),  on  the  conjunctival  limbus,  or  on  the 
cornea,  and  is  chiefly  a  disease  of  children  up  to  the  eighth  or 
tenth  year  of  age. 

*  Kipac^  a  horn. 

t  The  posterior  epithelium — or  even,  according  to  some,  this  along 
with  the  membrane  of  Descemet  and  the  posterior  layers  of  the  true 
cornea — is  to  be  reckoned  to  the  uveal  tract ;  while  the  true  cornea — or, 
according  to  some,  only  its  central  layers — is  a  modification  of  the 
sclerotic. 

X  Loc.  cit.,  Bd.  V,  Abth.  2,  p.  279. 

123 


124  DISEASES   OF   THE   EYE. 

Notwithstanding  the  derivation  of  the  word,  a  phlyctenula,  or 
phlyctene,  is  originally  neither  a  vesicle  nor  a  pustule;  but, 
when  on  the  conjunctiva,  is  a  solid  elevation  consisting  of  a  col- 
lection of  lymph  cells,  and  is  of  a  grayish  color.  In  a  late 
stage,  or  under  unsuitable  treatment,  the  phlyctenula  may,  it  is 
true,  become  a  pustule.  On  the  conjunctiva  two  types  of  the 
disease  may  be  recognized  : — 

1.  The  Solitary,  or  Simple,  Phlyctenula. — Of  this  there  may 
be  one  or  several,  varying  in  size  from  1  mm.  to  4  mm.  in  diameter. 
The  vascular  injection  is  immediately  around  the  phlyctenula, 
and  is  not  diffused  over  the  conjunctiva.  At  first  there  may  be 
shooting  pains  and  lachrymation,  but  these  soon  pass  away.  If 
the  phlyctenuhe  be  not  seated  close  to  the  cornea,  the  affection 
is  not  serious ;  and  the  length  of  time  required  for  its  cure  de- 
pends on  the  size  of  the  phlyctenuke,  varying  from  seven  to 
fourteen  days,  as  a  rule. 

2.  Multiple,  or  Miliary,  Phlyctenulse. — These  are  very  minute, 
like  grains  of  fine  sand,  and  are  always  situated  on  the  limbus 
of  the  conjunctiva,  which  is  swelled.  The  general  injection  and 
swelling  of  the  conjunctiva  are  considerable ;  and  occurring,  as 
it/loes,  almost  exclusively,  in  young  children,  the  affection  may 
be  called  Eczematous  Conjunctival  Catarrh  of  Children 
(Horner).  The  irritation,  and  so-called  photophobia,  and  lachry- 
mation, are  often  considerable,  and  there  is  a  good  deal  of  con- 
junctival discharge.  This  form  is  very  apt  to  appear  after 
measles  and  scarlatina. 

Bothfonm  are  liable  to  extend  to  the  cornea,  and  then,  only, 
does  the  disease  become  serious.  This  event  may  come  about  in 
the  following  different  ways: — 

The  Solitary  Phlyctenula  may  be  seated  partly  on  the  limbus 
conjunctivae  and  partly  on  the  margin  of  the  cornea,  and  may 
undergo  resolution. 

Or,  it  may  give  rise  to  a  deep  ulcer,  which  either  heals, 
leaving  a  scar,  or  perforates,  causing  prolapse  of  the  iris,  etc. 

Or,  it  may  form  the  starting-point  of  a  progressive  riband- 
like corneitis  (Fascicular  Keratitis),  the  pustule  becoming  an 


PHLYCTENULAR    OPHTHALMIA.  125 

ulcer,  at  the  margin  of  which  the  corneal  epithelium  is  raised 
and  infiltrated  in  crescentic  shape.  This  now  steadily  advances 
for  many  weeks  toward  the  centre  of  the  cornea,  followed  by  a 
leash  of  vessels  which  has  its  termination  in  the  concavity  of  the 
crescent.  The  process  is  accompanied  by  much  irritation  of  the 
terminal  branches  of  the  fifth  nerve  in  the  cornea,  and  the  con- 
sequent reflex  blepharospasm.  A  permanent  mark  indicates  the 
track  of  the  ulcer. 

The  Multiple  Miliary  Phlyctenulse  on  the  limbus  conjunctivae 
may  cause  some  slight  superficial  infiltration  and  vasculariza- 
tion of  the  cornea  in  their  immediate  neighborhood,  which  pass 
off  when  the  phlyctenule  disappear. 

Or,  they  may  be  accompanied  by  deeper  marginal  infiltrations 
of  the  cornea,  which  become  confluent  and  result  in  an  ulcer 
that  extends  along  the  margin  of  the  cornea  for  some  distance, 
and  is  termed  a  Ring  Ulcer.  It  is  a  serious  form  of  ulcer,  for, 
if  it  extend  far  round,  it  may  destroy  the  cornea  in  a  few  days 
by  cutting  off  its  nutrition. 

Primary  PMyctenular  Keratitis  occurs  principally  in  three 
diflferent  forms  :  1.  Very  small  gray  subepithelial  infiltrations, 
which  are  apt  to  turn  into  small  ulcers  and  then  heal,  leaving  a 
slight  mark.  This  mark  may  ultimately  quite  disappear, 
especially  in  the  case  of  children  and  when  situated  peripher- 
ally. 2.  Somewhat  larger  and  deeper  infiltrations,  resulting  in 
ulcers  of  corresponding  size,  which  heal  by  aid  of  vasculariza- 
tion from  the  margin  of  the  cornea.  The  opacity  left  after  these 
ulcers  is  rather  intense  and  clears  up  but  little,  especially  if  the 
situation  be  central.  3.  Large  and  deep-seated  pustules,  often 
at  the  centre  of  the  cornea,  giving  rise  to  large  and  deep  ulcers, 
which  may  be  accompanied  by  hypopyon  and  even  by  iritis,  and 
which  frequently  go  on  to  perforation. 

Photophobia  is  usually  a  prominent  symptom  in  phlyctenular 
keratitis.  The  term  photophobia,  however,  is  not  altogether 
correct,  for  it  is  the  fifth  nerve  (from  the  cornea)  which  is  mainly 
the  afferent  nerve  here,  rather  than  the  optic  nerve.  This  is 
evident  from  the  fact  that  in  the  dark  the  patient  does  not  get 


126 


DISEASES    OF   THE    EYE. 


complete  relief.  The  explanation  of  this  reflex  blepharospasm 
has  been  given  by  Iwanoff,*  who  showed  that  the  round  cells,  in 
making  their  way  from  the  margin  of  the  cornea  to  their  position 
under  the  epithelium,  follow  the  course  of  the  nerve  filaments, 
which  they  irritate  in  their  progress.  The  accompanying  Figs. 
5d  and  56  are  from  his  original  paper. 

Eczema  of  the  eyelids,  face,  and  external  ear,  and  catarrh  of 


Fig.  55. 


--  C 


E,  Epithelium  ;  B,  Ant.  elastic  Lamina;  C,  True  Cornea  ;  N,  Nerve  Filament,  with 
Lymph  Cells  on  its  Course  ;  D,  Phlyctenula. 


the   Schneiderian    mucous    membrane,   frequently   accompany 
phlyctenular  conjunctivitis  and  keratitis. 

In  these  cases,  in  children  of  three  or  four  years  of  age,  tem- 
porary amaurosis  has  sometimes  been  observed  after  a  severe  and 
long-continued  blepharospasm  has  passed  away.  The  patient 
is  found  to  be  unable  to  see  even  large  objects  or  to  find  its  way, 
although  the  pupil  reflex  is  active,  and  a  strong  light  may  still 
be   distressing.      There   are   no   ophthalmoscopic   appearances. 


*  Klin.  Monatsbldtter  f.  Augenheilkunde,  1869,  p. -465. 


PHLYCTENULAR    OPHTHALMIA.  127 

This  blindness  passes  away  completely  in  from  two  to  four 
weeks.  It  has  been  regarded  as  a  reflex  phenomenon,  and  again 
it  has  been  held  to  be  due  to  disturbance  of  the  intraocular  cir- 
culation from  pressure  of  the  eyelids  on  the  eyeball.  But  the 
view  (Leber-Uhthoff )  which  represents  it  as  having  a  central 
cause  is  probably  the  correct  one.  It  is  likely,  at  this  tender 
age,  when  the  psycho-physical  processes  are  not  as  yet  firmly 
established,  that  the  desire  not  to  see,  and  the  active  withdrawal 
from  the  act  of  vision,  leads  in  a  short  time  to  a  functional 
paralysis  of  the  visual  centres  in  the  brain ;  and  that  these  take 
some  time  to  recover,  or  to  re-learn  their  functions,  when  the 
ground  for  the  suspension  of  the  latter  has  ceased. 

Fig.  5G, 


IV 


Cause. — This  is  a  disease  of  childhood,  although  it  is  rare  in 
the  very  first  year  of  life.     In  adults  it  is  very  uncommon. 

The  strumous  constitution,  as  indicated  by  the  swollen  nose 
and  upper  lip,  and  sometimes  by  the  enlarged  lymphatics  in  the 
neck,  as  well  as  by  the  eczema  just  mentioned,  is  that  most  liable 
to  this  affection.  Often,  however,  it  will  be  found  in  strong 
children  with  apparently  perfect  general  health ;  but,  even  in 
them,  there  is  probably  some  allied  irregularity  of  nutrition,  of 
of  which  the  great  tendency  to  recurrence  of  the  eye  affection 
is  evidence. 

Colonies  of  straw-colored    micrococci   may  be  found  in   the 


128  DISEASES   OF   THE   EYE. 

contents  of  the  phlyctenulte  ;  but  what  etiological  relationship  to 
the  production  of  the  plilyctenuhc  they  possess  is  not  yet  known. 

Treatment — The  solitary  phlyctenula  is  best  treated  with  the 
yellow  oxide  of  mercury  ointment  *  (commonly  known  asPagen- 
stecher's  ointment),  of  which  the  size  of  a  hemp-seed  should  be 
put  into  the  eye  once  a  day.  Or,  a  small  quantity  of  pure  calo- 
mel dusted  into  the  eye  once  a  day  will  also  cure ;  but  this 
remedy  should  not  be  employed  if  iodide  of  potassium  is  being 
taken  internally,  for  then  iodide  of  mercury  is  liable  to  be 
formed  in  the  conjunctiva. 

The  miliary  phlyctenular  conjunctivitis  is  best  treated  at  first 
with  cold  or  iced  applications.  Freshly  prepared  chlorine  water 
(  1  part  Liq.  Chlori.,  9  parts  water),  to  be  dropped  into  the  eye 
once  a  day,  is  recommended  by  some,  and  later  on  Liq.  plumbi 
dil.  or  Sol.  argent,  nitr.  (grs.  v  ad  5J,  and  neutralized)  applied 
to  the  everted  conjunctiva  ;  or,  if  the  phlyctenular  appearances 
predominate  over  the  catarrhal,  the  yellow  oxide  of  mercury 
ointment,  or  insufflations  of  calomel,  may  be  preferred.  I  my- 
self rarely  employ  any  remedy  other  than  the  two  latter,  which 
I  find  applicable  to  all  these  cases. 

When  the  cornea  is  slightly  affected  near  the  margin,  in  cases 
of  miliary  phlyctenuke,  calomel,  or  Pagenstecher's  ointment, 
and  warm  fomentations  should  be  used. 

When  a  large  pustule  on  the  margin  of  the  cornea  has  resulted 
in  a  deep  ulcer,  with  tendency  to  perforate,  and  accompanied  by 
much  pain,  I  cannot  too  highly  recommend  paracentesis  of  the 
anterior  chamber  through  the  floor  of  the  ulcer,  the  pupil  having 
first  been  brought  well  under  the  influence  of  eserine,  to  pre- 
vent prolapse  of  the  iris.  The  good  effect  of  this  will  be  very 
soon    apparent:    the    pain  disappears,  the    patient   sleeps,    the 

*  R  .-^Hydrarg.  Perox.  Proecip.,  gr.  xxx.     Vaselin,  5J. — M. 

Note. — Hyd.  Perox.  Pra'cip.  is  prepared  by  precipitating  the  Bichlo- 
ride of  Mercury  with  Liq.  Sodce,  and  washing  the  resulting  oxide.  I 
learn  from  Mr.  Jabez  Hogg  that  this  ointment  was  in  use  by  the  late  Mr. 
Guthrie,  in  the  year  1849. 


PHLYCTENULAR   OPHTHALMIA.  129 

ulcer  becomes  vasoularized,  and  healing  sets  in.  Cauterization 
of  the  ulcer  in  an  early  stage  with  the  galvano-cautery  is  also 
good  practice ;  but  in  these  cases  I  prefer  the  paracentesis. 
Many  surgeons  trust  very  much  to  eserine,  warm  fomentations, 
and  a  pressure  bandage. 

For  the  fascicular  keratitis  the  yellow  oxide  of  mercury  oint- 
ment is  in  its  place.  When  the  crescentic  infiltration  is  very 
intense,  it  is  well  to  touch  it  with  the  galvano-cautery.  Division 
of  the  leash  of  vessels  at  the  margin  of  the  cornea  has  a  bene- 
ficial effect. 

For  the  ring  ulcer,  a  pressure  bandage,  under  which  an  anti- 
septic dressing  (boracic  or  salicylic  acid,  or  perchloride  of  mer- 
cury) has  been  placed,  is,  perhaps,  the  best  method  of  treatment. 
Warm  fomentations  promote  vascular  reaction,  and  may  be  used 
with  benefit  at  each  change  of  bandage. 

For  primary  phlyctenule  of  the  cornea  in  the  form  of  the 
minute  gray  superficial  infiltration  or  ulcer,  nothing  beyond 
atropine,  with  warm  fomentations  and  a  protective  bandage  to 
keep  the  eyelids  quiet,  should  be  used.  When  reparation  of  the 
ulcer  has  commenced,  calomel,  or  weak  yellow  oxide  of  mer- 
cury ointment,  may  be  employed. 

For  the  large  purulent  phlyctenula,  resulting  in  a  large  and  deep 
ulcer,  often  situated  at  the  centre  of  the  cornea,  with  hypopyon 
and  iritis,  warm  fomentations  (camomile,  or  poppy-head,  at  90° 
F.,  for  twenty  minutes  three  times  a  day),  atropine,  iodoform  as 
ointment  or  powder,  and  a  protection  bandage,  form  the  treat- 
ment in  the  early  stages.  Here,  also,  I  often  puncture  the 
ulcer,  with  the  very  best  results  in  respect  of  hastening  the  cure, 
and  the  galvano-cautery  may  be  used  with  advantage.  In  the 
stage  of  reparation,  Pagenstecher's  ointment,  or  insufflations  of 
calomel,  are  very  useful. 

In  all  forms  of  phlyctenular  ophthalmia,  those  favorite  reme- 
dies, blisters,  setons,  and  leeching,  should  be  avoided.  The  first 
two  worry  the  patient,  give  rize  to  eczema  of  the  skin,  and  are 
not  to  be  compared  in  their  power  of  cure  with  the  measures 
above  recommended  ;  while  leeching  gives,  at  best,  but  tempo- 


130  DISEASES   OF   THE   EYE. 

rary  relief,  and  deprives  the  patient  of  blood  which  he  much 
requires. 

For  relief  of  the  blepharospasm,  in  addition  to  the  use  of 
atropine,  plunging  the  child's  face  into  a  basin  of  cold  water, 
and  keeping  it  under  until  he  struggles  for  breath,  and  this 
immersion  repeated  two  or  three  times  in  rapid  succession,  and 
used  every  day  if  necessary,  is  a  most  efficacious  means.  It 
should  always  be  used  where  the  blepharospasm  is  severe,  as  this 
is  not  only  distressing  to  the  patient,  but  also  an  obstacle  to  the 
cure. 

The  general  treatment,  notwithstanding  the  so-called  photo- 
phobia, should  consist  in  open-air  exercise  before  everything 
else ;  unless,  indeed,  there  be  an  ulcer  which  threatens  to  perfo- 
rate. It  is  not  well  to  keep  the  patient's  face  or  eyes  covered 
with  bandages  and  shades.  A  pair  of  dark-blue  glasses  are  the 
best  protection  from  strong  glare  of  light ;  and  shaded  places 
can  be  selected  when  the  patient  is  out-of-doors.  Cold  or  sea 
baths,  followed  by  brisk,  dry  rubbing.  Easily  assimilated  food 
at  regular  meal  hours,  but  no  feeding  between  meals.  Regula- 
tion of  the  bowels.  Internally :  cod-liver  oil,  maltine,  iron, 
arsenic,  syr.  phosph.  of  lime,  and  such  like  remedies  are  indicated. 

The  great  tendency  to  recurrence  is  one  of  the  most  trouble- 
some peculiarities  of  all  kinds  of  phlyctenular  ophthalmia;  and, 
in  order  to  prevent  this,  so  far  as  possible,  it  is  important  to  con- 
tinue local  treatment,  until  the  eye  is  perfectly  white  on  the 
child's  awaking  in  the  morning,  and  even  for  fourteen  days 
longer.  This  prolongation  of  the  treatment  will  also  assist  in 
clearing  up  opacities,  as  best  they  may  be.  For  this  after- 
course  of  treatment  calomel  insufflations  should  be  used. 

Nothing  can  be  done  for  the  opaque  scars  left  on  the  cornea 
by  ulcers,  when  all  inflammatory  symptoms  have  subsided. 
If  the  ulcer  have  been  very  superficial,  the  resulting  scar  in 
young  children  may  disappear  in  the  course  of  time.  Deep 
ulcers  cause  more  opaque  and  permanent  scars,  and  ulcers  which 
have  perforated  produce  the  greatest  opacity.  Some  of  the  very 
disfiguring  scars  may  be  tattooed  (see  Chap.  VIII). 


PHLYCTENULAR    OPHTHALMIA.  131 

The  degree  of  the  defect  of  visioD  to  which  an  opacity  of  the 
cornea  may  give  rise  depends,  in  the  first  instance,  on  the  posi- 
tion of  the  opacity.  If  it  be  peripheral,  the  vision  may  be  per- 
fect ;  but,  if  it  be  in  the  centre  of  the  cornea,  sight  may  be 
seriously  damaged.  Even  a  slight  nebula,  barely  visible  to  the 
observer,  will  cause  serious  disturbance  of  vision  if  situated 
in  the  centre  of  the  cornea;  while,  in  the  same  situation,  the 
very  opaque  scar  of  a  deep  ulcer  will  produce  a  proportionately 
greater  defect.  If  a  central,  but  not  deep,  ulcer  should  not  be- 
come completely  filled  up  in  healing,  and  a  facet  remain,  vision 
will  also  suffer  much  in  consequence  of  irregular  refraction, 
although  there  may  be  but  little  opacity. 


CHAPTER  VI. 
DISEASES  OP  THE  EYELIDS. 

Erythema,  erysipelas,  phlegmonous  inflammation,  and  ab- 
scess are  all  liable  to  attack  the  eyelids,  but  require  no  special 
observations  in  this  work. 

It  should  merely  be  stated  that  erysipelas  of  the  eyelids  may 
extend  to  the  connective  tissue  of  the  orbit,  and  ultimately  give 
rise  to  atrophy  of  the  optic  nerve. 

Eczema. — This  is  very  often  seen  on  the  eyelids,  most  fre- 
quently in  connection  either  with  eczema  of  the  face  in  general 
or  with  phlyctenular  ophthalmia,  which  latter  is  to  be  regarded 
as  eczema  of  the  conjunctiva  and  cornea.  The  lachrymation  in 
phlyctenular  ophthalmia  increases  the  eczema,  which  then,  by 
causing  contraction  of  the  skin  of  the  lower  lid,  produces  ever- 
sion  of  the  inferior  punctum  lachrymale,  and  this,  in  its  turn, 
causes  increased  lachrymation,  and  thus  a  vicious  circle  is  set  up. 

Atropine  infiltration  of  the  eyelid,  from  long  use  of  solution 
of  atropine  in  some  persons,  is  often  accompanied  by  a  moist 
form  of  eczema  of  the  lids  and  face. 

Treatment  should  consist  in  the  daily  removal  of  the  scabs,  in 
such  a  way  as  to  cause  no  bleeding  of  the  surface  underneath  ; 
and,  for  this  purpose,  a  warm  solution  of  bicarbonate  of  potash 
is  useful.  The  place  should  afterward  be  well  dried,  and 
painted  with  a  strong  solution  of  nitrate  of  silver  (gr.  xx  ad  5J) 
and  a  boracic  acid  ointment  (gr.  xxx  ad  5J),  or  the  following, 
applied  over  this:  01.  Cadin,  n^xv;  Flor.  Zinci,  gr.  xx  ; 
Lanolin,  .^ij. — M.  If  the  inferior  lachrymal  punctum  be  everted, 
the  canaliculus  should  be  slit  up. 

Herpes  Zoster  ophthalmicus  is  an  herpetic  eruption,  which 
affects  the  region  supplied  by  the  supraorbital  division  of  the 

132 


THE    EYELIDS.  133 

fifth  nerve  of  one  side,  and  sometimes  its  nasal  branch,  and,  in 
rare  instances,  the  infraorbital  division  of  the  same  nerve.  The 
occurrence  of  the  eruption  is  preceded,  for  some  days,  by  severe 
neuralgic  pain  and  swelling,  with  redness  of  the  part.  The 
number  of  vesicles  varies  much,  and  may  be  but  three  or  four, 
or  so  numerous  as  to  become  confluent.  As  soon  as  the  eruption 
appears,  the  pain  usually  becomes  much  diminished,  and,  indeed, 
often  disappears.  Vesicles  are  liable  to  form  on  the  cornea,  and 
these  may  result  in  ulcers,  which,  on  healing,  leave  opacities. 
Iritis  has  also  been  observed  as  a  complication,  and  even  cyclitis, 
resulting  in  loss  of  the  eye.  The  vesicles  on  the  skin  soon 
become  purulent  and  gradually  turn  into  scabs,  which  fall  oflT 
and  leave  deeply  pitted  scars,  recognizable  during  the  remainder 
of  life.  The  affection  never  crosses  the  middle  line  of  the  fore- 
head. Some  neuralgia,  with  anaesthesia  of  the  skin,  may  remain 
for  a  long  time  afterward. 

Inflammation  of  the  Gasserian  ganglion,  with  extension  of  the 
inflammatory  process  down  the  nerve,  was  found  (O.  Wyss)  in 
the  only  case  in  which  a  7905^  mortem  examination  has  been 
made  durinor  the  acute  stacre  of  the  disease. 

The  afl?ection  is  most  common  in  elderly  people,  but  I  have 
seen  it,  also,  in  young  and  healthy  individuals. 

The  Treatment  can  only  be  expectant,  or,  at  most,  directed  to 
relief  of  the  patient's  suffering,  by  means  of  hypodermic  injec- 
tions of  morphia  and  other  sedatives,  and  by  emollients  applied 
locally.  Complications  in  the  cornea  and  iris  are  to  be  dealt 
with  on  the  principles  laid  down  in  the  chapters  on  the  diseases 
of  those  organs. 

Primary  Syphilitic  Sores  occur  on  the  eyelids,  usually  near 
the  margin  of  the  upper  or  lower  lid,  or  at  the  inner  or  outer 
canthus.  The  first  appearance  is  generally  a  "  pimple,"  which 
ulcerates  and  becomes  characteristically  indurated  about  its 
base.  The  margin  of  the  ulcer  is  clean-cut,  and  its  floor 
somewhat  excavated  and  covered  with  a  scanty  grayish  secre- 
tion. Occasionally  there  is  no  ulcer  present,  but  the  entire  lid 
is  swollen,  greatly  indurated,  purple,  and  shiny  ;  and  then  the 


134  DISEASES   OF   THE   EYE. 

diagnosis  may  be  rendered  difficult.  The  prseauricular  and 
submaxillary  glands  are  almost  always  swollen  ;  and  this  is  a 
valuable,  although  not  altogether  positive,  diagnostic  sign,  as  it 
is  seen  also  in  tubercular  diseases  of  the  conjunctiva.  The 
occurrence  of  the  sore  is  followed  by  the  usual  constitutional 
symptoms  of  syphilis.  Very  rarely  is  there  any  permanent 
damage  done  to  the  eyelid. 

The  most  common  modes  of  infection  are  by  a  kiss  from  a 
syphilitic  mouth  or  by  a  dirty  finger. 

Treatment. — Locally,  sublimed  calomel  by  Kane's  method, 
dusting  with  finely  powdered  iodide  of  mercury,  or  the  black 
wash  may  be  used  ;  while  the  usual  general  mercurial  treatment 
is  employed. 

Secondary  Syphilis  gives  rise  to  ulcers  on  the  margins  of  the 
lids,  to  loss  of  the  eyelashes  (madarosis),  and  to  the  secondary 
skin  afl^ections  which  attend  it  in  other  parts  of  the  body. 

Vaccine  Vesicles  on  the  eyelids  are  produced  by  accidental 
inoculation  at  the  intermarginal  part  of  the  lid;  or  on  the 
outer  surface  of  the  lid,  if  the  skin  be  abraded  by  the  finger- 
nail, or  otherwise.  Sometimes  the  vesicle  develops  into  a  large 
ulcer  with  yellowish  floor  and  hard  and  elevated  margin.  There 
is  much  pain,  much  swelling  of  the  eyelid,  and  chemosis. 

Although  distressing  for  a  week  or  so  while  it  lasts,  the 
affection  is  not  a  dangerous  one,  further  than  that  a  cicatrix  in 
the  skin  is  left  behind,  and  the  eyelashes  at  the  affected  part  are 
lost. 

Treatment. — A  warm  chlorate  of  potash  lotion  (gr.  v  ad  3J)  is 
the  best  application. 

Rodent  Ulcer  (Jacob's  Ulcer). — This  disease  commences  as  a 
small  pimple  or  wart  on  the  skin  near  the  inner  canthus,  or  over 
the  lachrymal  bone,  as  a  rule,  but  it  may  also  originate  in  any 
other  part  of  the  face.  The  scab  or  covering  of  the  wart  is 
easily  removed,  and  underneath  is  found  a  shallow  ulcer  with  a 
well-defined  indurated  margin,  the  skin  surrounding  the  dis- 
eased place  being  healthy  and  continuing  so  to  the  end  of  the 
chapter.     The  progress  of  the  disease  is  extremely  slow,  extend- 


THE   EYELIDS.  135 

ing  over  a  great  number  of  years,  and,  in  the  early  stages,  the 
ulcer  may  even  seem  to  heal  for  a  time,  but  always  breaks  out 
again.  In  mild  cases  the  ulceration  may  remain  superficial ; 
but,  more  usually,  it  strikes  deep,  in  the  course  of  time  eating 
away  every  tissue,  even  the  bones  of  the  face  and  the  eyeball. 
The  latter  is  often  spared  until  after  the  orbital  bones  have 
gone. 

The  disease  is  an  epithelial  cancer  of  a  non -malignant,  or 
purely  local,  kind.  There  is  no  tendency  to  infiltration  of  the 
lymphatics.  It  is  rarely  seen  in  persons  under  forty  years  of 
age. 

Treatment. — Extirpation  of  the  diseased  part  afiTords  the  best 
chance  of  relief  for  the  patient.  Recurrence  of  the  growth  is 
the  rule,  but  this  should  not  deter  from  operative  measures,  nor 
even  from  the  renewal  of  them,  as  they  aflford  much  comfort  to 
the  patient  and  prolong  his  life.  Even  in  advanced  stages 
operation  is  frequently  called  for.  The  application  of  chloride  of 
zinc  or  of  the  actual  cautery  should  be  employed,  after  the 
disease  has  been  as  thoroughly  removed  with  the  knife  as  is 
possible. 

My  friend,  Dr.  C.  E.  Fitzgerald,  informs  me  that  he  has  had 
some  remarkably  good  results  in  cases  of  rodent  ulcer  from  the 
use  of  Bergeon's  treatment.  This  consists  in  the  internal  ad- 
ministration of  five  grains  of  chlorate  of  potash  three  times  a 
day,  with  the  local  application  of  a  saturated  solution  of  chlo- 
rate of  potash  to  the  ulcer. 

Marginal  Blepharitis  ([iAi(fap<r^,  eyelid),  or  Ophthalmia 
tarsi,*  is  nothing  else  than  eczema  of  the  margin  of  the  eyelid. 
It  is  found  either  as  Blepharitis  ulcerosa  (Eczema  pustulosa), 
or  as  Blepharitis  squamosa  (Eczema  squamosa).  In  the  former, 
small  pustules  form  at  the  roots  of  the  eyelashes,  and  these, 
having  lost  their  covering,  become  ulcers,  which  scab  over. 
The  whole  margin  of  the  lid  may  then  be  covered  with  one  large 
scab,  in  which  the  eyelashes  are  matted,  and  under  which  the  lid 

*  The  term  tinea  tarsi  is  not  employed  in  modern  ophthalmology. 


136  DISEASES   OF   THE    EYE. 

will  l)e  found  swollen,  red,  and  moist,  with  many  minute  ulcers 
and  pustules.  Many  eyelashes  come  away  with  the  scab,  and 
many  others  are  found  h)ose  and  ready  to  fall  out. 

The  disease  is  chronic,  and  is  most  commonly  found  in  stru- 
mous children.  It  is  frequently  accompanied  by  phlyctenular 
ophthalmia,  or  by  simple  conjunctivitis,  which  may  have  been 
its  cause,  or  which  promotes  it  by  keeping  the  margin  of  the 
lid  constantly  wet. 

If  neglected,  ulcerous  blepharitis  is  liable  to  produce  trichia- 
sis by  giving  a  false  direction  to  the  bulbs  of  the  cilia 

Many  ophthalmologists  hold  that  blepharitis  is  often  caused 
by  ametropia,  especially  by  hypermetropia  or  hypernaetropic 
astigmatism,  in  consequence  of  the  incessant  efforts  of  accom- 
modation. I  cannot  go  thus  far ;  but  perhaps,  if  blepharitis  be 
once  set  up,  such  anomalies  of  refraction  may  help  to  keep  it 
going. 

The  Treatmeni  of  Ulcerous  BlepJiaritis  consists  in  careful  re- 
moval of  the  scabs  without  causing  any  bleeding  of  the  delicate 
surface  underneath.  Such  bleeding  indicates  that  the  newly 
formed  epithelium  has  been  torn  away,  and  it  is  important, 
therefore,  to  soften  the  scabs  by  soaking  the  eyelid  with  olive 
oil,  or  with  a  solution  of  bicarbonate  of  potash,  before  removing 
them.  Any  pustules  found  under  the  scab  should  be  punctured, 
and  all  loose  eyelashes  taken  away,  and  the  ulcers  touched  with 
a  fine  point  of  solid  mitigated  lapis.  The  surface  should 
then  be  well  dried  by  pressure,  not  by  rubbing,  with  a  soft 
cloth,  and  the  following  ointment  (Hebra)  applied:  R.  01. 
Rusci  (or,  01.  Juniperi)  .^ss,  Hydrarg.  Amnion.  Chlor.  gr.  iv, 
Cer.  Galeni,  Lanolin  aa  ^ij.  This  ointment  is  to  be  continued 
until  healing  is  thoroughly  established.  In  many  mild  cases  a 
boracic  acid  ointment  (gr.  v  ad  ^j  of  Vaselin,  or  of  Lanolin) 
will  be  found  efficacious  instead  of  the  above,  and  a  \yhite 
Precipitate  Ointment  of  from  1  to  2  per  cent,  acts  well.  A  cre- 
olin  ointment  suits  many  cases,  viz.,  Creolin,  1  to  5  min. ;  Aq., 
.^ij  ;  Lanolin,  .^vj. 

Or,  again,  after  the  scabs  and  loose  eyelashes  have  been  re- 


THE   EYELIDS.  137 

moved  as  above,  the  margins  of  the  eyelids  may  be  freely  bathed 
with  a  wash  of  ten  to  twenty  minims  of  creolin  to  eight  ounces 
of  water,  as  recommended  by  Dr.  Glasgow  Patteson  for  chronic 
eczema,*  and  after  this  the  creolin  ointment  may  be  applied.  I 
have  found  this  method  very  successful.  But  in  all  cases,  what- 
ever the  lotion  or  ointment  ordered  may  be,  the  ulcers  should  be 
touched  with  mitigated  lapis,  as  above  recommended,  and  all 
loose  eyelashes  removed. 

All  complications  with  conjunctival  affections  or  lachrymal 
obstruction  must  be  dealt  with,  and  the  patient's  general  sys- 
tem carefully  attended  to.  Any  error  in  refraction  should  be 
suitably  corrected. 

Squamous  Blepharitis  comes  on  after  the  ulcerous  form  has 
passed  away ;  or,  it  is  found  as  a  primary  affection,  especially  in 
chlorotic  women.  The  margin  of  the  lid  is  somewhat  swollen 
and  red,  and  covered  with  loose  epidermic  scales.  It  is  an  ex- 
tremely chronic  affection. 

The  Treatment  of  Squamous  Blepharitis  is  also  an  ointment  of 
Hebra's : — 

B:.  Emplast.  Diachylon  Co.,  f  5j ;  01.  Olivae,  q.  s. 

or,  the  Boracic  Acid  ointment  may  be  used. 

Chlorosis,  if  present,  is  to  have  suitable  remedies. 

Phtheiriasis  {^Oz\f),  a  louse)  ciliorum. — The  pediculus  pubis 
occurs  on  the  eyelashes.  It  gives  rise  to  excessive  itching  and 
burning  sensations,  and  the  consequent  rubbing  produces  ex- 
coriations of  the  margin  of  the  lid.  The  lice  occupy  chiefly  the 
roots  of  the  eyelashes,  while  the  shafts  of  the  cilia  are  covered 
with  their  brown  egg-capsules,  and  this  gives  to  the  cilia  the 
peculiar  appearance  of  being  covered  with  dark  brown  powder, 
which  enables  the  diagnosis  to  be  easily  made.     The  fully  de- 


*  Dub.  Joitrn.  Med.  Sciences,  July,  1891. 

t  Emplast.   Diachylon  Co.    is   made   as  follows :     Emplast.   Litharg. 
B.  P.,  12  parts  ;  Corn  flour,  IJ  part ;  Ammoniac,  Galbanum,  Turpentine, 
of  each  1  part. 
12 


138  DISEASES   OF   THE    EYE. 

veloped  parasites,  as  well  as  the  eggs,  may  be  more  readily  seen 
by  aid  of  a  strong  convex  glass. 

Treabnent. — With  a  cilium  forceps  the  pediculi  may  be,  to  a 
great  extent,  if  not  completely,  removed,  as  well  as  some  of  the 
eggs  from  the  cilia.  This  proceeding  repeated  daily,  along  with 
the  application  of  Mercurial  Ointment,  or  of  a  weak  Red  Pre- 
cipitate Ointment,  to  the  margin  of  the  eyelids,  morning  and 
evening,  will  soon  effect  a  cure. 

Hordeolum  (hordeam,  a  grain  of  barley),  or  Stye,  is  a  circum- 
scribed purulent  inflammation,  situated  at  the  follicle  of  an 
eyelash.  It  commences  as  a  hard  swelling,  with  more  or  less 
tumefaction  and  oedema  of  the  general  surface  of  the  lid,  and 
often  with  some  chemosis,  especially  if  it  be  situated  at  the  outer 
canthus.  In  its  early  stages  there  is  much  pain  associated  with 
it.  It  gradually  suppurates,  and  may  then  be  punctured  or 
allowed  to  open  of  itself. 

Styes  frequently  come  in  rapid  succession  one  after  the  other, 
and  then,  probably,  a  constitutional  disturbance  exists  as  the 
cause.  In  the  earliest  stage  cold  applications  may  be  successful 
in  putting  back  a  stye,  but  later  on  warm  stupes  will  hasten  the 
suppuration  and  relieve  the  pain.  Habitual  constipation  is  a 
common  source  of  hordeolum,  and  should  be  met  by  the  occa- 
sional use  of  Cascara  Sagrada,  or  of  Friedrichshall,  or  Hunyadi 
Janos  water,  or  some  other  mild  laxative.  Sulphide  of  calcium. 
To  S^-  every  hour,  or  i  gr.  twice  a  day,  for  an  adult,  has  been 
recommended  (D.  Webster)  as  a  specific  in  these  cases. 

Chalazion  (ydXa^a,  hail),  Meibomian  Cyst,  or  Tarsal  Tumor, 
is  a  granuloma  in  connection  with  a  Meibomian  gland.  It  has 
its  origin  in  a  chronic  inflammatory  process  in  the  connective 
tissue  surrounding  the  gland,  which  usually  passes  ofl*  without 
having  attracted  the  attention  of  the  patient.  These  tumors 
vary  in  size  from  that  of  a  hemp-seed  to  that  of  a  hazel-nut, 
causing  a  marked  and  very  hard  swelling  in  the  lid.  They 
occasionally  open  spontaneously  on  the  conjunctival  surface, 
giving  exit  to  contents  which  are  usually  viscid  or  gruraous,  but 
sometimes  purulent. 


THE    EYELIDS.  139 

Treatment. — No  application  can  bring  about  absorption  of 
these  tumors.  The  lid  should  be  everted,  the  tumor  opened  by 
a  single  incision  from  the  conjunctival  surface,  and  its  contents 
thoroughly  evacuated  by  aid  of  a  scoop  or  small  sharp  spoon. 
Difficulty  is  sometimes  experienced  in  finding  the  point  in  the 
conjunctiva  corresponding  to  the  tumor,  but  it  is  usually  indi- 
cated by  a  dusky  or  grayish  discoloration.  Immediately  after 
the  evacuation  bleeding  into  the  sac  often  takes  place,  and 
causes  the  tumor  to  remain  for  a  day  or  more,  as  large  as  before, 
a  fact  of  which  the  patient  should  be  warned.  The  operation 
may  occasionally  require  to  be  repeated  two  or  three  times.  The 
interior  of  the  sac  should  not  be  touched  with  nitrate  of  silver ; 
and  the  incision  and  evacuation  should  never  be  made  through 
the  skin,  because  more  or  less  disfigurement  from  the  scar  would 
result. 

More  than  one  chalazion  is  often  present  at  a  time,  and  some 
people  become  liable  to  them  periodically  daring  a  number  of 
years. 

Milium  (milium,  a  millet  seed)  presents  the  appearance  of  a 
perfectly  white  tumor,  not  much  larger  than  the  head  of  a  pin, 
in  the  skin  of  the  eyelid.  It  is  a  retention  tumor  of  a  sebaceous 
gland,  and  can  readily  be  removed  by  puncture  and  evacuation. 

MoUuscum,  or  MoUuscum  contagiosuin. — This  is  a  white 
tumor  in  the  skin  of  the  eyelid,  which  may  attain  the  size  of  a 
pea.  At  its  summit  is  a  depression,  which  leads  to  an  opening 
into  the  tumor,  through  which  the  contents  can  be  pressed  out. 
It  is  probably  a  diseased  condition  of  a  sebaceous,  gland,  and 
contains  altered  epithelial  cells  and  peculiar  bodies  termed  mol- 
luscum  corpuscles,  which  are  of  a  fatty  nature.  Many  such 
tumors  may  form  in  the  lids  at  the  same  time. 

It  is  held  by  some  observers  that  this  affection  is  contagious, 
although  in  what  way  is  not  clear,  inasmuch  as  experimental 
rubbing  of  the  contents  of  a  molluscum  into  the  skin  has  not 
given  rise  to  the  tumors. 

Treatment. — Each  separate  tumor  must  be  evacuated  by 
simple  pressure,  or  after  it  has  been  opened  up  with  a  knife  or 
scissors. 


140  DISEASES   OF   THE    EYE. 

Teleangiectic  Tumors,  or  Naevi,  of  the  eyelids  occur  congeni- 
tally. 

Treatment. — Small  tumors  of  this  kind  may  be  destroyed  by 
touching  with  nitrate  of  silver  or  hydrochloric  acid,  or  by  per- 
forming vaccination  on  them.  Larger  tumors  may  be  liga- 
tured or  treated  with  the  galvano-cautery,  and  electrolysis  is  a 
very  effectual  method  in  many  cases. 

Xanthelasma  (Xa-yOo^,  yellow;  llaniia^  a  layer)  is  the  term 
applied  to  yellowish  plaques  raised  slightly  over  the  surface  of  the 
skin,  with  very  defined  margins.  The  shape  of  these  plaques  is 
extremely  irregular,  and  they  may  attain  the  size  of  a  shilling 
or  larger.  The  appearance  is  caused  by  hypertrophy  of  the 
sebaceous  glands,  with  retention  of  their  contents,  and  fatty 
degeneration  of  the  subcutaneous  connective  tissue. 

Treatment  can  only  consist  in  removal  by  careful  dissection, 
and  this  is  hardly  to  be  recommended,  except  in  extreme  cases. 

Palpebral  Chromidrosis  {yjiwiw.^  color ;  'lopoiaiq,  sweatijig). — 
The  phenomenon  of  an  exudation  of  pigment  upon  the  eyelids, 
of  which  about  fifty  cases  have  been  recorded,  has  given  rise  to 
much  discussion.  The  opinion  held  by  many  is  that  these  cases 
are  always  the  result  either  of  deception  in  hysterical  individu- 
als, or  of  accidental  circumstances,  such  as  the  exposure  of  a 
patient  with  seborrhoea  palpebrarum  to  an  atmosphere  loaded 
with  coal-dust  or  pigmentary  matter,  in  some  manufacturing 
district.  Of  the  fact  that  the  appearance  has  occurred  under 
both  of  these  conditions  there  can  be  no  doubt.  There  would 
seem  also  to  be  evidence  that  some  genuine  cases  of  color-sweat- 
ing on  the  eyelids  have  been  observed,  but  they  must  be  ex- 
tremely rare.  The  discoloration  is  blue  or  black,  and  occurs  in 
the  form  of  fine  powder  upon  the  skin  of  one  or  both  eyelids 
of  both  eyes.  It  can  be  wiped  off,  and  is  said  to  begin  to  reap- 
pear after  a  short  interval.  The  subjects  of  it  have  been  chiefly 
young  girls,  but  it  has  also  been  seen  in  women  of  advanced 
years,  and  even  in  middle-aged  men. 

The  Treatment  in  a  genuine  case  may  consist  in  the  appli- 
cation of  a  lotion  of  Liq.  plumbi  and  glycerine ;  and,  internally, 
iron,  quinine,  and   arsenic,  along   with   the  regulation   of  the 


THE    EYELIDS.  141 

general  system,  particularly  in  respect  of  any  uterine  de- 
rangement. 

Epithelioma,  Sarcoma,  Adenoma,  and  Lupus  are  all  seen  in 
the  eyelids,  but  require  no  special  description  here. 

Clonic  Cramp  of  the  Orbicularis  Muscle,  or  of  a  portion  of  it, 
is  often  seen,  and  is  popularly  known  by  the  name  of  "  life  "  in  the 
eyelid.  It  is  frequently  due  to  overuse  of  the  eyes  for  near  work, 
especially  by  artificial  light,  or  if  there  be  defective  amplitude 
of  accommodation. 

Treatment  should  consist  in  the  regulation  of  the  use  of  the 
eyes  for  near  work,  and  the  correction  by  glasses  of  any  defect 
in  the  accommodation. 

Blepharospasm,  or  Tonic  Cramp  of  the  Orbicularis  Muscle, 
is  commonly  the  result  of  irritation  of  the  ophthalmic  division 
of  the  fifth  nerve  by  reflex  action,  as  in  phlyctenular  ophthalmia 
and  some  other  corneal  and  conjunctival  affections;  or,  from 
foreign  bodies  on  the  conjunctiva  and  cornea,  etc. ;  or,  it  may 
continue  for  some  time  after  the  relief  of  any  such  irritation. 
It  occurs,  also,  independently  of  such  causes,  and  is  then  difficult 
to  account  for,  unless  as  a  hysterical  symptom.  Yet  even  in 
these  obscure  cases  the  spasm  is  probably  often  a  reflex  from  the 
third  nerve,  and  it  will  found  that  pressure  upon  the  supra- 
orbital nerve  at  the  supraorbital  notch  may  arrest  the  spasm  ; 
or,  if  not  there,  then  pressure  on  the  infraorbital,  temporal, 
malar,  or  inferior  alveolar  branch  may  have  the  desired  eflfect ; 
or,  at  even  still  more  remote  regions,  and  in  the  course  of  other 
nerves,  the*"  pressure  point  "  may  be  discovered. 

Treatment. — If  the  cause  of  the  reflex  cannot  be  ascertained, 
or  have  passed  away,  and  the  cramp  be  very  distressing, 
stretching  or  resection  of  the  branches  of  the  fifth  nerve,  from 
which  the  reflex  proceeds,  may  be  tried.  Morphium  hypoder- 
mically  has  been  of  use  in  some  cases,  but  it  would  be  undesir- 
able to  continue  this  treatment  for  long. 

Ptosis  (-Tojo-c?,  a  fall),  or  Blepharoptosis,  is  an  inability 
to  raise  the  upper  lid,  which  then  hangs  down  over  the  eye- 
ball.    It  is  either  congenital  or  acquired ;    and,  in  the  latter 


142  DISEASES   OF   THE   EYE. 

case,  is  most  usually  the  result  of  paralysis  of  the  branch  of  the 
third  nerve  supplying  the  levator. 

Persons  affected  with  ptosis  involuntarily  endeavor  to  raise  the 
eyelid  by  an  over-action  of  the  frontalis  muscle.  The  drooping 
lid  and  elevated  eyebrow  give  a  peculiar  and  characteristic 
appearance. 

The  Causes  of  Paralytic  Ptosis  are  similar  to  those  of  paralysis 
of  other  branches  of  the  third  pair,  more  especially  exposure 
to  cold  draughts  of  air  while  the  body  is  heated,  and  syphilis  or 
rheumatism  affecting  the  branch  to  the  levator  palpebr?e  in  its 
course.  It  may  also  be  due  to  focal  cerebral  disease."^  The 
branch  to  the  levator  may  be  paralyzed  alone,  or  in  conjunc- 
tion with  other  third  nerve  branches,  and  the  loss  of  power 
may  be  partial  or  complete. 

The  Treatment  of  a  recent  case  of  ordinary  paralytic  ptosis 
depends  upon  its  cause.  If  this  be  syphilis,  then  a  course  of 
mercurial  inunctions  or  of  iodide  of  potassium  ;  if  rheumatism, 
then  salicylate  of  soda  or  iodide  of  potassium ;  with,  in  either 
case,  protection  of  the  eye  and  side  of  the  head  with  a  warm 
bandage.  Cases  in  which  these  remedies  have  failed,  and  which 
have  become  chronic,  often  demand  operative  treatment. 

Ptosis  due  to  a  cerebral  lesion  rarely  comes  within  the  scope 
of  treatment. 

Operative  Treatment  is  indicated  in  cases  of  paralytic  ptosis 
— where  other  measures  have  produced  no  result — in  ptosis 
adiposa,  and  in  congenital  cases.  A  very  common  proceeding 
consists  in  the  excision  of  a  sufficiently  large  oval  piece  of 
integument,  its  long  axis  lying  in  the  length  of  the  lid,  with  the 
subcutaneous  connective  tissue  and  fat,  and,  in  paralytic  cases, 
a  small  portion  of  the  orbicular  muscle.  The  fold  of  integument 
to  be  abscised  is  seized  by  two  pairs  of  forceps — one  of  them  held 
by  an  assistant — at  the  inner  and  outer  ends  of  the  lid,  and  by 
this  means  the  necessary  size  of  the  fold  is  estimated.  The 
abscission  is  performed  with  a  pair  of  scissors,  the  margin  of  the 

*The  value  of  ptosis  as  a  locahzing  symptom  in  the  cerebral  disease 
will  be  treated  of  in  Chap.  XVIII. 


THE   EYELIDS. 


143 


wound  lying  close  to  the  points  of  the  forceps.  The  subcuta- 
neous tissue,  etc.,  is  then  removed,  and  the  edges  of  the  wound 
drawn  together  by  a  few  points  of  suture. 

Pagenstecher' s  Method  is  as  follows :  Its  object  is  to  enable  the 
patient  to  derive  more  benefit  from  the  effort  of  his  frontalis 
muscle,  which  he  is  constantly  making  with  so  little  result,  by 
transferring  its  action  more  directly  to  the  eyelid.  A  needle 
carrying  a  thick  ligature  is  entered  under  the  skin  of  the  fore- 
head, about  half  an  inch  above  the  centre  of  the  eyebrow,  and 
passed  subcutaneously  as  far  as  the  margin  of  the  eyelid  at  its 
middle  point.  The  suture  is  closed,  not  very  tightly  at  first,  but 
each  day  somewhat  more  tightly, until  it  has  cut  its  way  through 
the  skin.  As  the  result  of  this,  a  cicatrix  is  formed  in  the  course 
of  the  ligature,  which  gives  the  frontalis  much  more  power  over 
the  eyelid.  I  have  tried  this  method,  but  I  have  not  been 
satisfied  with  it.  Fig.  57. 

Panas'  Method.  *  — 
The  object  of  this 
operation  is  to  bring 
about  a  union  between 
the  lid  and  the  fron- 
talis muscle,  by  form- 
ing a  flap  in  the 
former,  which  is  fas- 
tened to  the  skin  of 
the  forehead,  and  to 
the  surface  of  the 
muscle. 

Before  the  operation 
commences,  and  while 
it  is  in  progress,  an 
assistant  applies  his 
hand  firmly  to  the 
patient's  forehead,  in 
such  a  way  as  to  prevent  shifting  of  the  skin  of  the  eyelid  over 

*  Archives  d'  Ophthalmologic,  Janvier-Fevrier,  1886. 


144 


DISEASES   OF   THE   EYE. 


the  underlying  tissues,  which  would  interfere  with  the  exactitude 
of  the  proceeding. 

A  horn  lid-spatula  is  inserted  under  the  lid,  and  Fig.  57 
explains  how  the  eyelid  flap  is  formed.  The  horizontal  incision 
along  the  top  of  the  flap  has  a  slight  convexity  upward,  is  not 
quite  an  inch  long,  lies  over  the  orbital  margin,  and  goes 
through  all  the  tissues  down  to  the  periosteum.  Another  incision, 
parallel  to  this  one,  rather  more  than  an  inch  long,  is  made 
along  the  upper  border  of  the  eyebrow,  and  as  deep  as  the  perios- 
teum. The  flap  of  skin  and  muscle  is  now  dissected  from  the 
tarsus  down  to  its  ciliary  border,  but  the  suspensory  ligament  of 
the  lid  must  not  be  interfered  with.  The  bridge  of  tissue 
between  the  two  horizontal  incisions  is  now  to  be  undermined 
without  injury  to  the  periosteum  or  suspensory  ligament.  The 
flap  is  then  drawn  up  under  the  bridge  by  means  of  the  sutures 

(act),   and   secured   to 
^^^-  ^^'  the  upper  edge  of  the 

upper  incision.  Inas- 
much as  the  traction  ex- 
ercised by  the  flap  when 
so  fixed  tends  to  produce 
ectropion  of  the  lid, 
two  lateral  sutures  (b  h') 
are  applied  deeply 
through  the  suspensory 
ligament  and  conjunc- 
tiva, to  the  exclusion  of 
the  skin,  and  are  at- 
tached, like  the  other 
~^  '  sutures,    to    the    upper 

lip  of  the  upper  in- 
cision, thus  counteracting  the  tendency  to  ectropion.  Fig.  58 
shows  the  eflect  of  the  operation. 

Fuchs  has   published*  some  cases  of  bilateral  ptosis,  which 


Vr,-,,^^^-^^> 


*Von  Graefe's  Archiv,  xxxvi,  1,  p.  234. 


THE    EYELIDS.  145 

were  due,  in  his  opinion,  to  primary  atrophy  of  the  levator  pal- 
pebrse  muscles.  The  eyelids  were  elongated  and  thinned,  so  that 
the  eyeball  showed  plainly  through  them.  The  loss  of  power 
had  in  each  case  been  very  slowly  increasing  for  many  years. 

Congenital  ptosis  is  generally  present  in  both  eyes.  It  is  due, 
in  some  cases,  to  an  imperfect  development  of  the  levator  pal- 
pebrse ;  and,  in  others,  to  an  abnormal  insertion  of  this  muscle, 
its  tendon  being  attached  to  the  tarsus  too  far  back.  Either 
Pageustecher's  or  Panas'  operation  may  be  employed  here. 
Eversbusch  has  proposed*  the  following  proceeding  more  particu- 
larly for  congenital  ptosis  : — 

EversbuscKs  Operation  for  Congenital  Ptosis. — The  object  of 
the  operation  is  to  increase  the  power  of  the  levator  by  ad- 
vancing its  insertion,  or  rather  by  doubling  it  down  over  the 
tarsus  where  it  forms  fresh  adhesions.  Snellen's  lid  clamp  is 
applied,  so  that  the  plate  is  passed  well  up  into  the  fornix ;  and, 
before  the  ring  is  screwed  down  the  skin  of  the  lid  is  drawn  down 
so  that  its  prolongation  just  under  the  eyebrow  may  be  forced 
into  the  instrument.  The  skin  and  the  underlying  orbicularis 
are  now  divided  in  the  entire  width  of  the  lid,  parallel  to  its  free 
margin,  and  at  a  distance  half-way  between  this  margin  and  the 
eyebrow.  The  skin  and  the  subjacent  muscle  are  then  separated 
up,  both  upward  and  downward,  for  4  mm.  in  each  direction,  so 
that  the  insertion  of  the  levator  may  be  well  exposed.  A  suture 
with  a  small  curved  needle  at  either  end  is  then  introduced  by 
means  of  one  of  these  needles,  horizontally  into  the  tendon  at  its 
insertion,  and  near  the  centre  of  the  latter,  in  such  a  way  that 
about  2*  mm.  of  the  tendon  may  be  included  in  the  suture. 
Each  needle  is  now  passed  vertically  downward  between  the 
tarsus  and  orbicularis,  and  brought  out  at  the  free  margin  of  the 
lid  at  a  distance  from  each  other  of  about  2 2  mm.  Two  more 
such  double  sutures,  one  in  the  temporal,  the  other  in  the  nasal 
third  of  the  tendon,  are  similarly  applied.  The  margins  of  the 
horizontal  skin  and  muscle  wound  are  now  drawn  together,  and 

*Monatshl.f.  Augeiihk.,  1883,  p.  100. 
13 


146 


DISEASES   OF   THE    EYE. 


then  the  three  sutures  are  closed  tightly.  It  is  desirable  to  slip 
glass  beads  over  the  ends  of  the  sutures  before  tying  thera,  to 
prevent  cutting  into  the  margin  of  the  lid.  Both  eyes  are  ban- 
daged, and  the  sutures  left  in  for  a  week  or  more.  Figs.  59  and 
60  serve  to  render  the  foregoing  explanation  more  lucid.  Con- 
genital ptosis  is  sometimes  associated  with  epicanthus.  (See  end 
of  this  chapter.) 

A  remarkable  condition  is  Congenital  Ptosis  with  Associated 
Movements  of  the  Affected  Eyelid  during  the  action  of  certain  mus- 


FiG.  59. 


Fig.  60. 


/,  levator  palpebrte ;  o,  orbicularis. 


cles.  There  are  only  about  fifteen  cases  of  this  on  record.  They 
all  agree  in  this  particular,  that  the  upper  lid  affected  with  ptosis 
— most  commonly  the  left  lid — is  raised  when  the  mouth  is 
opened.  A  synchronous  contraction  of  the  pupil  has  been 
noticed  in  some  cases,  while  in  some  the  elevation  of  the  lid  occurs 
also  with  a  lateral  motion  of  the  jaw,  and  with  deglutition.  It 
is  probable  that  in  these  cases  the  levator  is  not  wholly  supplied 
by  the  third  nerve,  but  partly  also  by  nerve  fibres  which  take 


THE   EYELIDS.  147 

their  origin  in  the  nucleus  of  the  fifth  pair,  and  which  also 
supply  the  external  pterygoid  and  digastric  muscles.  Needless  to 
say,  no  remedy  can  be  applied  for  relief  of  this  condition. 

The  term  "  ptosis"  is  also  given,  although  not  very  correctly, 
to  cases  in  which  increased  weight  of  the  lid  causes  it  to  droop,  as 
in  conjunctival  aflfections,  or  where  a  tumor  has  formed  in  the 
eyelid,  or  where  there  is  a  hyper-development  of  the  subcutane- 
ous fat. 

Lagophthalmos  (/.ay 6^,  a  /lare,  as  it  was  supposed  that  this 
animal  sleeps  with  its  eyes  open ;  o<f6aX/j.6^),  or  inability  to  close 
the  eyelids,  is  most  commonly  due  to  paralysis  of  the  portio  dura, 
and  is  then  associated  with  the  other  symptoms  of  the  latter 
affection.  On  an  effort  to  close  the  lids  being  made,  the  eyeball 
is  rotated  upward  under  the  upper  lid,  owing  to  the  associated 
action  of  the  superior  rectus  ;  and  in  sleep  this  upward  rota- 
tion also  occurs— a  fact  which  explains,  to  a  great  extent,  the 
immunity  of  the  cornea  from  ulceration  in  many  of  these  cases. 
Lagophthalmos  may  also  be  due  to  orbital  tumors  pushing  the 
eyeball  forward,  to  exophthalmic  goitre,  to  staphyloma,  or  to  in- 
traocular growths  distending  the  walls  of  the  eyeball ;  in  all  of 
which  conditions  the  eyelids  are  often  mechanically  prevented 
from  closing  over  the  eyeball,  or  can  be  closed  only  by  a  strong 
effort  of  the  wall.  The  danger  to  the  eye  depends  upon  the  ten- 
dency to  ulceration  of  the  cornea  from  its  dryness,  caused  by 
exposure  to  the  air,  and  from  foreign  substances  not  being  removed 
from  it  by  nictitation. 

When  lagophthalmos  occurs  as  a  symptom  in  focal  cerebral 
disease,  it  is  useful  in  localizing  the  disease,  by  assisting  in  differ- 
entiating a  lesion  in  the  internal  capsule,  or  in  the  facial  motor 
centre  of  the  cortex,  from  one  implicating  the  portio  dura  in  the 
pons,  as  it  is  absent,  or  very  slight,  in  the  former  cases,  but  very 
often  markedly  present  in  the  latter.  With  a  lesion  in  the  lower 
part  of  the  pons  we  are  apt  to  have  lagophthalmos  with  crossed 
hemiplegia  ;  but,  if  the  lesion  be  in  the  upper  part  of  the  pons — 
the  fibres  from  the  opposite  side  having  here  joined  the  motor 
tract — the  hemiplegia  and  lagophthalmos  will  be  homonymous. 


148  DISEASES   OF   THE    EYE. 

Treatment. — In  cases  of  non-piiralytic  lagophthalmos,  pro- 
tection of  the  cornea,  by  keeping  the  eyelids  closed  with  a  band- 
age, or  a  few  epidermic  sutures  in  the  margins  of  the  eyelids, 
should  be  our  first  care.  Tarsorraphy  may  be  employed  in 
those  cases  where  circumstances  indicate  that  it  would  be  useful, 
e.  g.,  in  some  cases  of  exophthalmic  goitre,  or  of  staphylomatous 
eyeball. 

In  paralytic  cases  the  primary  cause  of  the  paralysis  (syphilis, 
rheumatism,  etc.)  must  be  treated,  so  long  as  there  is  a  prospect 
of  restoriDg  power  to  the  muscles.  Locally,  galvanism  and 
hypodermic  injections  of  strychnia  may  be  employed.  During 
cure,  the  cornea  should  be  protected  as  above.  In  incurable 
cases  the  opening  of  the  eyelids  must  be  reduced  considerably 
in  size  by  an  extensive  tarsorraphy. 

The  Operation  of  Tarsorraphy  consists  in  uniting  the  margins 
of  the  upper  and  lower  lids  in  the  neighborhood  of  the  external 
commissure,  so  as  to  reduce  the  size  of  the  opening  of  the  eye- 
lids. The  commissure  should  be  caught  between  the  finger  and 
thumb,  and  the  edges  of  the  lids  approximated,  so  as  to  enable 
the  operator  to  form  an  estimate  of  the  required  extent  of  the 
operation.  A  horn  spatula  is  then  passed  behind  the  commis- 
sure, and  the  necessary  length  of  the  margin  of  each  lid, 
including  the  bulbs  of  the  cilia,  abscised  with  a  sharp  knife. 
The  raw  margins  are  then  brought  together  with  sutures. 

Symblepharon  (^uv  together;  ^Ucpapov  the  eyelid^  is  an 
adherence,  partial  or  complete,  of  the  eyelid  to  the  eyeball.  It 
is  usually  the  result  of  burns  of  the  conjunctiva  by  fire,  acids, 
or  lime.  The  shortening  of  the  conjunctival  sac,  which  is  seen 
as  the  result  of  pemphigus,  or  of  granular  ophthalmia,  and 
which  I  have  above  described  under  the  heading  of  Xerophthal- 
mos,  is  sometimes,  but  I  think  wrongly,  called  Symblepharon. 
If  the  symblepharon  interfere  seriously  with  the  motions  of  the 
eyeball,  or  if  it  cause  defect  of  vision  by  obscuring  the  cornea, 
it  becomes  desirable  to  relieve  it  by  operation.  Should  it  con- 
sist of  a  simple  band  stretching  from  lid  to  eyeball,  it  may  be 
severed  by  ligature,   and,  if  the  band  be]  broad,  two  ligatures 


THE    EYELIDS.  149 

may  be  employed,  Ohe  for  either  half.  A  symblepharon  which 
occupies  a  considerable  surface  cannot  be  got  rid  of  in  this  way, 
and,  for  such  cases,  a  transplantation  procedure  like  that  of 
Teale*  or  of  Knappf  may  be  employed,  the  great  difficulty  in 
dealing  wdth  these  cases  being  the  tendency  there  is  to  reunion 
of  the  surfaces,  unless  one  or  both  of  them  be  carpeted  with 
epithelium. 

In  Teales  Operation,  if  we  suppose  the  case  to  be  similar  to 
that  represented  in  Fig.  61,  an  incision  is  carried  along  the  line 
of  the  margin  of  the  cornea  at  A,  through  the  whole  thickness 
of  the  symblepharon,  and  the  lid  is  dissected  off  from  the  eye- 
ball as  far  as  the  fornix.  Two  conjunctival  flaps  are  now 
formed,  as  at  B  and    C  in  Fig.  62,  and  one  of  them  {B)  is 

Fir;,  fii.  Fig.  62.J 


turned  to  form  a  covering  for  the  wounded  surface  of  the  inside 
of  the  eyelid,  while  the  other  (C)  is  used  to  cover  the  bulbar 
surface  (Fig.  63),  the  flaps  being  held  in  their  places  by  fine 
sutures.  That  part  of  the  symblepharon  which  is  left  adherent 
to  the  cornea  soon  atrophies  and  disappears.  No  great  tension 
of  the  flaps  should  exist  as  they  lie  in  their  new  positions. 

*  Ophthal.  Eosp.  Rep.,  Vol.  iii. 

■f  Archivf.  Ophthal.,  xiv,  pt.  1,  p.  270. 

X  Mr.  Teale  now  makes  his  flaps,  as  in  Fig.  62,  wider  than  he  originally 
did.  I  have  to  thank  him  for  altering  this  drawing  with  his  own  hand 
for  this  work. 


150 


DISEASES   OF   THE   EYE. 


Fig.  63. 


Teale,  again,  has  suggested  the  formation  of  a  bridge-like 
conjunctival  flap  above  the  cornea,  and  the  removing  of  it 
across  the  latter  to  cover  the  loss  of  substance  situated  below. 
After  the  sutures  to  keep  the  flap  in  its  place  have  been  intro- 
duced, the  latter  is  separated  at  its  bases. 

A  simple  plan,  which  would  be  applicable  to  such  a  case  as 
that  depicted  in  Fig.  61,  where  the  adhesion  is  not  very  exten- 
sive, and  perhaps  even  to  some  more  extensive  ones,  consists  in 

dissecting  the  conjunctival  pro- 
cess off  the  cornea,  and  then  turn- 
ing it  down  on  the  raw  inner  sur- 
face of  the  under  lid,  and  fasten- 
ing it  there  with  a  suture  or  two.  I 
have  done  this  with  complete  sat- 
isfaction. 

The  transplantation  of  a  portion 
of  a  rabbit's  conjunctiva,  as  sug- 
gested by' Wolfe,  or  of  a  portion  of  mucous  membrane  from 
the  lips,  or  from'  the  vagina,  as  employed  by  Stellwag,  is  un- 
doubtedly the  best  method  for  many  cases  of  extensive  symble- 
pharon.  The  chief  precautions  necessary  for  success  in  this 
proceeding  are :  That  the  flap  to  be  transplanted  be  not  applied 
in  its  new  position  until  all  bleeding  at  the  latter  place  has 
ceased.  That  the  flap  be  nothing  more  than  mucous  membrane, 
all  sub-raucous  tissue  being  carefully  removed.  That  it  be  suffi- 
ciently large  to  cover  the  defect  without  any  stretching  ;  and  it 
should  be  remembered,  that  the  flap  shrinks  to  two-thirds  of  its 
size  after  being  detached  from  its  own  bed.  That  the  flap  be 
kept  moist  and  warm  during  the  period,  as  short  as  possible, 
which  may  elapse  between  its  detachment  and  its  adjustment. 
And,  finally,  that  it  be  kept  firmly  in  its  new  position  by  a  suffi- 
cient number  of  points  of  interrupted  suture. 

Harlan's  Operation.''^ — This  is  specially  applicable  to  extensive 
symblepharon  of  the  lower  lid,  and  differs  from   the  foregoing 


*  Ophth.  Rev.,  Vol.  ix,  p.  351. 


THE   EYELIDS.  151 

operations  in  that  it  provides  a  covering  of  skin,  and  not  of 
mucous  membrane,  for  the  raw  surface  of  the  under  lid.  Opera- 
tions on  the  same  principle  have  been  proposed  by  Snellen  and 
by  Kuhnt.  An  incision  A  B  (Fig.  64)  through  the  whole  thick- 
ness of  the  eyelid,  and  correspond-  ^ 

.1         ,  11  .1  Fig.  64. 

ing  in  length  to  the  latter,  is  made 

along  the   lower    margin    of    the 

orbit.     Below  this  a  skin  flap  C 

D   is   then  formed.      The   flap  is 

dissected  up,  and  the  incisions  are 

carried  a  little  more  deeply  as  A 

B  is  approached,  to  enable  the  flap 

to  turn  more  readily.     The  flap  is  then  turned  up  as  on  a  hinge, 

slipped  through  the   button-hole,  and   sutured  securely  to   the 

inner  surface  of  the  under  lid.     After  a  time  the  skin  surface 

turned  toward  the  eyeball  becomes  considerably  modified,  so  as 

to  be  somewhat  like  mucous  membrane.     The  bare  space  left  by 

the  removal  of  the  strip  of  skin  is  covered  without  strain,  by 

making  a  small  horizontal  incision,  D  E,  at  its  -outer  extremity, 

and  forming  a  sliding  flap. 

Blepharophimosis  (,?/cc?a,oov,  eyelid;  ci/j.ojfTi<;,  narrowing)  is  a 
contraction  of  the  outer  commissure  of  the  lids,  with  consequent 
diminution  in  size  of  the  opening  between  the  latter  ;  and  is 
commonly  due  to  shortening  of  the  skin,  from  long-continued 
irritation  of  it,  caused  by  the  discharge  in  a  case  of  conjunc- 
tivitis. 

It  is  remedied  by  a  Canthoplastic  Operation.  The  outer  com- 
missure is  divided  in  its  entire  thickness,  in  a  line  which  is  a 
prolongation  of  the  line  of  junction  of  the  lids  when  closed,  by 
a  single  stroke  of  a  strong  straight  scissors,  one  blade  of  which 
has  been  passed  behind  the  commissure.  The  integumental  in- 
cision should  be  made  a  little  longer  than  that  in  the  conjunctiva. 
An  assistant  then  draws  the  upper  lid  up  and  the  lower  lid 
down,  so  as  to  make  the  wound  gape.  The  conjunctival  margin 
and  the  dermic  margin  are  now  united  in  the  centre  by  a  point 
of  suture  (C,  Fig.  %o),  while  two  more  sutures  (A  and  B)  are 


152 


DISEASES   OF   THE    EYE. 


applied,  one  above  and  the  other  below  the  first.  This  operation 
is  also  employed  in  cases  of  granular  ophthalmia,  and  of  puru- 
lent conjunctivitis,  when  it  is  desired  to  relieve  the  pressure  of 
the  lid  on  the  globe. 

Distichiasis  (m^,  ticice;  <j':iyo(s^aroiv)j  and  Trichiasis  (rptyo?,  a 
hair). — The  first  of  these  terms  indicates  the  growth  of  a  row 
of  eyelashes  along  the  intermarginal  portion  of  the  lid,  in  addi- 
tion to  the  normal  row  ;  while  trichiasis  indicates  a  false  direc- 

FiG.  65. 


{De  Wecker.) 

tion  given  to  the  true  cilia.  Both  conditions  are  often  found 
coexisting,  and  they  are  also  often  present  along  with  entropium. 
They  may  both  be  produced  by  chronic  blepharitis,  or  by  chronic 
granular  ophthalmia.  It  has  been  commonly  held  that  cicatricial 
contraction,  giving  a  false  direction  to  the  hair  follicles,  is  the 
immediate  cause  of  these  conditions  ;  but  Raehlmann  has  re- 
cently *  shown   that  the  false  cilia  are  developed   as   buds  or 


*  Von  Graefe's  Archiv,  xxxvii,  2,  p.  66. 


THE   EYELIDS.  153 

offshoots  from  the  follicles  of  the  cilia,  and  primarily  from  the 
cuticle  of  the  free  margin  of  the  lid.  The  latter  mode  of  devel- 
opment is  a  novel  discovery  by  Raehlmann,  which  he  seems  to 
have  definitely  proved  by  his  pathological  investigations.  His 
view  is,  that  hyper?emia  of  the  margins  of  the  lids  and  inflam- 
mation of  a  proliferating  type  is  what  gives  rise  to  this  primary 
development  of  hairs.  The  symptoms  to  which  they  give  rise, 
and  the  dangers  to  the  eye  attendant  on  them,  are  due  to  the 
rubbing  of  the  irregular  eyelashes  on  the  cornea,  which  pro- 
duces pain,  blepharospasm,  and  opacity  of  the  cornea,  or  even 
ulceration  of  it. 

Ojyerations  for  Distichiasis  and  Trichiasis : — 

Epilation. — The  false  cilia  may  be  pulled  out  with  a  forceps ; 
but  this  cannot  be  regarded  as  a  cure,  for  the  hairs  grow  again. 

Electrolysis  has  been  proposed  by  Dr.  Charles  Mitchell,  of 
Missouri,"^  and  by  Dr.  A.  Benson,  of  Dublin.^  A  needle  is 
attached  to  the  negative  pole,  and  its  point  passed  into  the  bulb 
of  the  eyelash  to  be  removed,  the  positive  pole  being  placed  on 
the  temple.  On  closure  of  the  circle  a  slough  is  formed  at  the 
root  of  the  hair,  which  becomes  loose,  and  is  removed.  It  does 
not  grow  again,  for  the  bulb  is  destroyed.  Each  hair  must  be 
separately  operated  on.  The  proceeding  is  very  valuable  where 
only  a  few  cilia  are  to  be  dealt  with. 

Illaquceatio. — Snellen  has  revived  this  ancient  operation  for 
cases  where  only  a  few  isolated  hairs  are  out  of  order.  Both 
ends  of  a  bit  of  very  fine  silk  thread  are  passed  through  the 
eye  of  a  fine  needle,  so  as  to  form  a  loop.  The  needle  is  now 
entered  as  close  to  the  point  of  exit  of  the  hair  as  possible,  and 
the  counter  puncture  is  made  in  the  position  which  the  hair 
should  normally  occupy  in  the  row  of  its  fellows.  The  needle 
is  drawn  completely  through,  as  also  the  ends  of  the  thread,  but 
the  loop  not  as  yet.     Into  the  loop  the  eyelash  is  now  inserted 

■^"Trichiasis  and  Distichiasis,  their  Nature  and  Pathology,  with  a 
Radical  Method  of  Treatment"  ;  and  Klin.  Monatsbl.,  April,  1882. 
t  Brit.  Med.  Journal,  December  16,  1882. 


154 


DISEASES   OF   THE   EYE. 


by  aid  of  a  fine   forceps,  and,  by  traction  on  the  ends  of  the 
thread,  loop  and  eyelash  are  drawn  Fig.  66. 

through  the  tunnel.  Unfortunately, 
the  eyelashes  frequently  regain  their 
abnormal  position  by  reason  of  their 
own  elasticity. 

Excision. — When,  some  half-dozen 
hairs  close  together  are  growing  wrong, 
the  simplest  and  best  plan  is  to  completely  remove 
them  by  excision  of  the  corresponding  portion  of 
the  ciliary  margin.  A  fine  knife  is  passed  into  the 
intermarginal  region,  at  the  place  corresponding  to 
the  hairs  to  be  dealt  with,  and  a  partial  division  of 
the  lid  into  two  layers,  as  in  the  Arlt-Jaesche  opera- 
tion (vide  infra)  is  effected.  A  V-shaped  incision  in 
the  skin  of  the  lid  is  then  made,  including  the  erring 
hairs,  the  whole  flap  is  excised,  and  the  margin  of 
the  loss  of  substance  drawn  together  with  sutures. 

In  cases  of  distichiasis  or  trichiasis,  involving  the 
whole  length  of  the  eyelid,  removal  of  the  marginal 
portion  of  skin  containing  the  bulbs  of  all  the 
eyelashes,  true  and  false  (Flarer's  operation),  is  not 
to  be  recommended — unless,  occasionally,  in  the 
underlid — because  it  unnecessarily  deprives  the  eye 
of  an  ornament  and  of  a  protection  against  glare  of 
sun  and  foreign  bodies. 

Transplantation,  or  Shifting,  of  the  marginal  portion  of  the 
integument  containing  the  hair  bulbs,  true  and  false,  is  a  prefer- 
able proceeding  in  these  complete  cases.  One  of  the  oldest  and 
most  valuable  operations  of  this  kind  is  that  of  Jaesche,  modi- 
fied by  Arlt.  It  is  performed  as  follows  :  Knapp's,  or  Snellen's, 
clamp  (Fig.  QQ)  having  been  applied  to  prevent  bleeding,  the 
lid  in  its  whole  length  is  divided  in  the  intermarginal  part  into 
two  layers  (Fig.  67),  the  anterior  containing  the  orbicular  mus- 
cle and  integument  with  all  the  hair  bulbs,  the  posterior  con- 
taining the  tarsus  and   conjunctiva.     The  incision  in  the  inter- 


THE    EYELIDS. 


155 


Fig.  67. 


marginal  portion  is  about  5  mm.  deep.  A  second  incision  is  now 
made  through  the  integument  of  the  lid,  parallel  to  its  margin, 
and  from  5  to  7  mm.  removed  from  it.  This  incision  also  ex- 
tends the  whole  length  of  the  lid.  A  third  incision  is  carried 
in  a  curve  from  one  end  to  the  other  of  the  second  incision. 
The  height  of  the  curve  is  proportional  to  the  effect  required, 
varying  from  4  mm.  to  7  mm. 
The  piece  of  integument  included 
between  the  second  and  third 
incisions  is  dissected  off  with 
forceps  and  scissors,  without  any 
of  the  underlying  muscle  being 
touched,  and  the  margins  of  the 
loss  of  substance  are  brought 
together  by  sutures.  By  this 
procedure  the  lower  portion  of 
integument  containing  the  hairs 
and  their  bulbs  is  drawn  up,  and 
away  from  contact  with  the 
cornea. 

Spencer  Watson,*  Nicati,! 
Schoeler,J  Burchard,§  Dianoux,|| 
and  Gayet  ^  have  all  proposed 
double  transplantation  opera- 
tions. 

Dianoux's  Operation  is  as  follows :  Snellen's  (or  de  Wecker's) 
clamp  is  applied  (omitted  in  figures  for  simplicity),  and  an  in- 
cision (Fig.  68)  is  made  parallel  to  the  free  margin  of  the  lid, 
about  4  mm.  from  it,  extending  the  whole  length  of  the 
lid,  and  penetrating  to  the  tarsus,  but  not  through  the  latter. 
The  ciliary  portion  of  the  lid,  marked  off  by  this  means,  is  now 
detached  from  the  tarsus  by  an  incision  on  the  intermarginal 


*  Ophthal  Hosp.  Rep.,  Vol.  vii,  1873,  p.  440.  f  Marseille  Medicale,  1879. 
X  Klinischer  Bericht,  1880.  |  Charite  Armalen,  p.  633. 

II  Annales  d'  Oculistique,  1882,  p.  132.  ^  Ann.  d'  Ocul,  1882,  p.  27. 


156 


DISEASES   OF   THE   EYE. 


portion  of  the  lid,  as  in  the  Arlt-Jaesche  operation.  An 
incision  through  the  skin  alone  is  then  made  about  3  mm. 
above  the  first  incision  and  parallel  to  it,  but  extending  some 
2  mm.  beyond  it  at  either  extremity.  The  skin  flap  is  separated 
off"  from  the  underlying  muscle,  except  at  either  end,  where  it 
is  left  attached.  The  underlying  portion  of  the  muscle  is  then 
separated  from  the  tarsus,  and  allowed  to  retract  upward.  A 
forceps  being  passed  under  the  ciliary  flap  (Fig.  68),  the  skin 
flap  is  seized  and  drawn  down  into  the  position  of  the  former 
(Fig.  69),  where  it  is  made  fast  by  three  sutures  to  the  margin 
of  the  tarsus.      The   ciliary  flap  is  moved  up,  and   carefully 


Fig.  68. 


Fig.  69. 


stretched  upon  the  tarsus  bared  of  the  orbicularis,  the  latter 
being  drawn  back  with  a  strabismus  hook,  and  the  flap  is 
secured  in  its  place  by  sutures  to  the  tarsus.  An  antiseptic 
dressing  is  applied,  and  the  sutures  may  be  removed  on  the 
third  day.  Although  the  wounded  surface  of  the  ciliary  flap 
does  not  become  vitally  united  with  the  epidermic  surface  of 
the  skin  flap,  yet  no  practical  ill  result  follows. 

A  real  objection  lies  in  the  circumstance  that,  occasionally, 
the  cutaneous  hairs  on  the  transplanted  flap  irritate  the  cornea, 
and  these  hairs,  being  much  finer  than  cilia,  are  more  difficult 
to  deal  with. 


THE   EYELIDS.  157 

Vossius's  Operation.''— liy  for  example  (Fig.  70),  the  whole 
extent  of  the  right  upper  lid  be  affected  with  trichiasis,  a  horn 
lid  spatula  (the  clamp  will  not  answer)  is  passed  under  the 
lid  and  held  by  an  assistant.  An  intermarginal  incision  is 
made,  as  in  the  Arlt-Jaesche  operation,  about  3  mm.  to  4  mm. 
deep.  The  incision  is  then  prolonged  through  the  skin  merely, 
over  the  external  commissure  for  5  mm.  to  6  mm.  It  is  then 
turned  upward  at  an  angle  with  the  free  margin  of  the  lid 
about  35°,  and  a  flap  about  5  mm.  wide  is  marked  out  with  the 
knife  in  the  usual  crease,  or  fold,  of  the  upper  lid.  A  narrow, 
sharp,  and  pointed  scalpel  is  then  thrust  under  the  flap  at  its 

Fig.  70. 


base,  and  carried  toward  its  inner  end,  so  as  to  separate  it  off" 
without  the  aid  of  forceps,  scissors,  or  any  other  instrument. 
The  margins  of  the  wound  thus  made  are  brought  together 
with  four  or  five  sutures,  and  the  flap  turned  down  and  secured 
in  the  gaping  intermarginal  incision  by  means  of  four  or  five 
sutures  between  each  of  its  edges  and  the  corresponding  palpe- 
bral margin.  One  suture  fastens  the  free  end  of  the  flap  in  the 
median  corner  of  the  wound.  The  position  of  the  cicatrix,  just 
in  the  fold  of  the  upper  eyelid,  prevents  its  causing  any  dis- 
figurement.    Were  the  case  one  of  partial  trichiasis,  the  inter- 

*Bericht  d.  Ophthal.  Geselhch.  (Heidelberg,  1887),  p.  42. 


158 


DISEASES   OF   THE   EYE. 


marginal  incision  should  extend  a  little  beyond  the  point  where 
the  abnormal  condition  ceases.  If  it  be  the  inner  half  only  of 
the  margin  of  the  lid  which  is  affected,  the  intermarginal  in- 
cision is  prolonged  toward  the  nose,  and  the  flap  so  formed 
that  its  base  lies  over  the  inner  canthus.  The  flap  heals  in 
readily,  and,  although  it  shrinks  somewhat,  secures  a  wide  inter- 
marginal portion.  The  same  drawback  in  connection  with  the 
cutaneous  hairs  on  the  transplanted  flap  holds  good  here,  as  in 
Dianoux's  operation. 

Vail  Millingen's  Operation"^'  consists  in  splitting  the  eyelid,  as 

Fig.  71. 


in  the  Arlt-Jaesche  operation,  from  end  to  end,  sufficiently  to 
produce  a  gap  {B,  Fig.  71)  3  mm.  in  width  at  the  central  part 
of  the  lid,  and  gradually  becoming  narrower  toward  the  canthi. 
The  gap  is  kept  open  by  sutures  passed  through  folds  of  skin  on 
the  upper  lid  (a,  a,  a),  by  means  of  which  also  the  lid  is  pre- 
vented from  closing  for  twenty-four  hours  at  the  least.  As  soon 
as  the  bleeding  has  ceased,  a  strip  of  mucous  membrane  of  the 
same  length  as  that  of  the  lid,  and  2  to   2^   mm.  in  breadth,  is 


*  Ophthalmic  Review,  1887,  p.  309. 


THE    EYELIDS.  159 

cut  out  with  two  or  three  snips  of  a  curved  scissors,  from  the 
inner  surface  of  the  patient's  under  lip,  and  is  placed  at  once 
into  the  gap  in  the  intermarginal  space.  It  should  then  be 
pressed  into  position  with  a  pledget  of  cotton  wool  steeped  in 
sublimate  solution  (1  in  5000).  Sutures  are  superfluous,  and  do 
more  harm  than  good.  The  eyelid  is  then  covered  over  with 
a  piece  of  lint,  on  which  is  spread  a  thick  layer  of  iodoform 
vaseline,  and  on  this  is  placed  a  wad  of  cotton  wool.  Both  eyes 
should  be  bandaged.  The  sublimate  lotion  is  used  for  disinfect- 
ing the  eye  and  lip  during,  before,  and  after  the  operation.  The 
bandage  should  be  renewed  once  in  twenty-four  hours,  and  the 
sutures  in  the  upper  lid  ought  not  to  be  removed  before  the 
second  day. 

Van  Millingen  does  not  think  it  advisable  to  transplant  small 
strips  of  mucous  membrane  if  the  trichiasis  be  partial.  He  re- 
gards this  condition  as  only  the  commencement  of  complete 
trichiasis,  and  therefore  recommends,  even  in  these  cases,  the 
filling  up  of  the  entire  length  of  the  intermarginal  space  with  a 
flap  of  mucous  membrane.  In  cases  of  shortening  of  the  con- 
junctival surface,  in  which  it  has  been  reduced  to  2  cm.,  a  strip 
of  mucous  membrane  measuring  4  mm.  in  width  at  the  centre 
may  be  transplanted. 

The  strip  to  be  transplanted  is  generally  taken  from  the  angle 
of  the  lip,  and  from  the  line  of  demarcation,  between  the  dry 
and  moist  surfaces  of  the  lip.  A  couple  of  fine  sutures,  which 
serve  to  unite  the  margins  of  the  wound  in  the  lip,  arrest 
the  bleeding  at  once,  and  accelerate  union  of  the  part,  which  is 
generally  completed  in  twenty-four  hours. 

The  transplanted  tissue  in  this  instance  being  free  from  hairs, 
the  method  is  not  open  to  the  objection  referred  to  in  Dianoux's 
and  in  Vossius's  operation,  while  it  is  equally  eflTectual  in  perma- 
nently providing  a  good  intermarginal  space,  and  in  thus  reliev- 
ing the  condition. 

Entropium  (iv,  in;  rpi-w,  to  turn),  or  Inversion  of  the  Eyelid, 
is  due  to  some  organic  change  in  the  conjunctiva  or  tarsus,  or  to 
spasm  of  the  palpebral  portion  of  the  orbicular  muscle. 


160  DISEASES   OF   THE   EYE. 

A  large  proportion  of  the  former  class  of  cases  is  the  result 
of  chronic  granular  ophthalmia,  and  is  most  common  in  the 
upper  lid. 

Spastic  entropium  usually  occurs  in  the  under  lid.  It  is  fre- 
quent in  old  people  (senile  entropium)  from  relaxation  of  the 
skin  of  the  eyelid,  and  is  also  produced  by  the  wearing  of  a 
bandage  after  operations,  etc.,  and  by  oedema  of  the  conjunctiva 
in  inflammation  of  that  membrane. 

Treatment. — Organic  entropium,  in  which  the  tarsus  is  not 
distorted,  can  often  be  corrected  by  one  of  the  methods  described 
for  trichiasis  and  distichiasis.  But  many  of  these  cases  are  ac- 
companied by,  or  rather  are  due  to,  abnormal  curvature  with 
hypertrophy  of  the  tarsus. 

In  all  such  cases  the  operation  must  include  an  attack  on  the 
tarsus  itself,  or  the  result  will  be  abortive.  Indeed,  I  have  little 
doubt  that  much  of  the  disappointment  experienced  in  the  treat- 
ment of  entropium  has  been  due  to  imperfect  appreciation  of 
this  fact. 

StreatfielcVs  Operation  is  as  follows  :  The  clamp  having  been 
applied,  an  incision  is  made  through  the  integument  of  the  eye- 
lid parallel  to  its  margin,  2  mm.  distant  from  the  latter,  and 
extending  its  whole  length.  The  muscle  is  dissected  up  so  as  to 
lay  bare  the  tarsus,  and  then  a  wedge-shaped  piece,  2  ram.  wide 
and  the  length  of  the  lid,  its  edge  pointing  toward  the  inner 
surface  of  the  lid,  is  excised  from  the  tarsus.  A  corresponding 
portion  of  muscle  and  skin  is  also  removed,  and  the  wound  left 
to  heal  by  granulation.  The  shrinking  of  the  resulting  cicatrix 
causes  the  marginal  portion  of  the  tarsus  to  return  to  its  correct 
position. 

Snellen's  Operation. — Snellen's  clamp  (very  similar  to  Kuapp's, 
which  can  equally  well  be  used)  is  applied.  About  3  mm.  from 
the  margin  of  the  lid,  and  parallel  to  it,  an  incision  is  made 
through  the  skin  alone,  extending  the  whole  length  of  the  lid. 
The  orbicular  muscle  is  exposed  by  dissection  of  the  skin  up- 
ward, in  order  to  promote  retraction  of  the  latter,  and,  along  the 
edge  of  the  lower  margin  of  the  wound,  a  strip,  about  2  mm. 


THE   EYELIDS. 


161 


broad,  of  the  orbicular  muscle  is  removed,  and  the  tarsus  to  the 
same  extent  exposed  to  view.  A  wedge-shaped  piece,  correspond- 
ing to  the  exposed  part  of  the  tarsus,  is  now  excised  from  it 
with  a  very  sharp  scalpel  or  Beer's  cataract  knife,  the  edge  of 
the  wedge  pointing  toward  the  conjunctiva,  which  latter,  how- 
ever, is  left  intact.  The  hypertrophy  of  the  tarsus,  which  is 
always  present,  facilitates  this  procedure.  A  silk  suture  carry- 
ing a  needle  on  each  end  having  been  prepared,  one  needle  is 
passed  from  within  outward  through  the  band  of  muscle  and 
integument  left  at  the  margin  of  the  lid.     The  second  needle  is 


Fig.  72. 


Fig.  73. 


/   \ 


also  passed  from  within  outward  through  the  upper  lip  of  the 
tarsal  loss  of  substance,  and  then,  from  within  outward  through 
this  same  marginal  band,  at  a  distance  of  about  4  mm.  from  the 
point  of  exit  of  the  first  needle.  The  ends  of  the  suture  are  now 
tied  together,  a  small  bead  having  first  been  strung  on  each  to 
prevent  it  from  cutting  through  the  skin.  Three  such  sutures 
are  employed.  The  accompanying  wood-cuts  (Figs.  72  and  73) 
make  the  foregoing  description  more  intelligible. 

Green's  Operation* — An  incision  is  made  on  the  inner  surface 
of  the  lid,  in  a  line  parallel  to,  and  about  2  mm.  distant  from,  the 


Trans.  American  Ophthal.  Soc,  Vol.  iii,  p.  167, 


14 


162  DISEASES   OF   THE   EYE. 

row  of  openings  of  the  Meibomian  ducts.     It  is  carried  through 
Fig  74  ^^^  conjunctiva  and  whole  thickness  of  the  tarsus, 

and  should  extend,  in  cases  of  complete  entropium, 
from  near  the  inner  to  the  outer  canthus.  A 
strip  of  skin  about  2  ram.  broad  and  tapering 
to  a  point  at  each  end  is  now  excised  from  the  lid, 
the  lower  margin  of  the  strip  being  1*  mm.  above 
the  line  of  the  eyelashes.  The  muscle  is  left  in- 
tact. Fine  silk  sutures  are  applied  in  the  follow- 
ing manner,  by  aid  of  a  No.  12  glover's  needle  bent  to  an  arc 
of  about  a  third  of  a  circle.  The  needle  is  first  introduced  a 
little  to  the  conjunctival  side  of  the  row  of  eyelashes,  and  is 
brought  out  just  within  the  wound  made  by  the  excision  of  the 
strip  of  skin  (Fig.  74,  A)  ;  it  is  then  drawn  through,  inserted 
again  in  the  wound  near  its  upper  margin,  and  passed  deeply 
backward  and  upward,  so  as  to  graze  the  front  of  the  tarsus 
and  emerge  through  the  skin  a  centimetre  or  more  above  its 
point  of  entrance  (Fig.  74,  B).  On  tying  the  two  ends  of  the 
thread  together  the  skin  wound  is  closed,  and  the  loosened 
lid  margin  is  at  the  same  time  everted  and  brought  into  a  cor- 
rect position.  Three  sutures  generally  suffice  for  the  accurate 
adjustment  of  the  lid  margin.  In  the  spaces  between  and  be- 
yond the  sutures  it  is  often  practicable,  and  advantageous,  to 
turn  the  eyelashes  upward  against  the  front  of  the  eyelid,  and 
fix  them  there  by  means  of  collodion.  The  stitches  should  be 
removed,  at  latest,  on  the  day  after  the  operation  ;  the  line  of 
suture  being  then  strengthened  by  collodion,  or,  in  case  the  cilia 
are  very  short,  a  few  short  fibres  of  cotton  are  used  with  the 
collodion. 

Berlin's  Ojyeration. — Knapp's  clamp  is  applied.  The  first 
incision  lies  3  mm.  above  the  margin  of  the  lid,  extends  its 
whole  length,  and  divides  it  in  its  entire  thickness,  including  the 
conjunctiva.  The  skin  and  muscle  at  the  upper  edge  of  the 
wound  are  pushed  or  dissected  up,  so  as  to  expose  the  tarsus. 
The  upper  edge  of  the  tarsal  incision  is  now  seized  at  its  centre 
with  a  finely  toothed  forceps,  and  an  oval  piece  with  the  adherent 


THE    EYELIDS. 


163 


coDJunctiva,  about  2  to  3  mm.  wide  in  its  widest  part,  and  in 
length  corresponding  with  that  of  the  eyelid,  is  excised  from  it 
with  a  fine  scalpel.  The  wound  is  closed  with  three  sutures 
through  the  skin.  If  it  be  thought  desirable  to  increase  the 
effect,  a  skin-flap  may  be  excised  from  the  lid.  The  objection 
to  this  operation,  that  a  portion  of  the  mucous  membrane  is 
removed,  is  not  of  importance.  Except  for  an  occasional  granu- 
lation forming  on  the  bulbar  aspect  of  the  wound,  I  have  found 
the  operation  free  from  inconvenience,  and  its  result  satisfactory, 
and,  in  most  instances,  permanent. 

Spastic  Entropium,  as  the  result  of  bandaging,  usually  disap- 
pears when  the  use  of  the  bandage  is  given  up,  or,  if  the  band- 
age must  be  continued  and  the  inverted  lid  cause  irritation,  an 
epidermic  suture  at  the  palpebral  margin  and  fastened  to  the 
cheek  below  will  give  relief. 

Senile  Entropium  is,  of  spastic  kinds,  the  one  which  most 
commonly  demands  operative  interference.  The  methods  in 
general  use  for  it  are : — 

The  Excision  of  a  Horizontal  Piece  of  Skin,  with  a  portion  of 
the  underlying  orbital  part  of  the  orbicular  muscle,  so  as  to  give 
rise  to  sufiicient  cicatricial  contraction  to  draw  the  margin  of 
the  lid  outward. 

The  application  of  Subcutaneous  Sutures  (  Gaillard^s  Sutures). — 
The  point  of  acurved  needle 
carrying   a  silk  suture  is  ^^' 

entered  in  the  centre  of 
the  lid  near  its  margin, 
passed  deeply  into  the  orbi- 
cular muscle,  brought  out 
at  a  point  some  10  mm. 
below,  and  the  suture  tied 
tightly.  Two  more  similar 
sutures,  one  on  either  side 
of  the  first  and  about  5  mm. 
distant  from  it,  are  placed, 
and  the  resulting  suppura- 
tion, with  consequent  cicatrization,  brings  the  lid  into  its  position. 


164 


DISEASES   OF   THE   EYE. 


Von  Graefes  Operation. — 3  mm.  from  the  margin  of  the  lid 
an  incision  is  made,  as  in  Fig.  75,  through  the  skin,  and  a  tri- 
angular skin-flap.  A,  excised.  The  edges,  B  and  C,  of  the 
triangle  are  dissected  up  a  little,  and  brought  together  by  three 
points  of  suture,  while  the  horizontal  incision  is  not  sutured. 
The  size,  especially  the  width,  of  the  triangular  flap  to  be  excised 
is  proportional  to  the  looseness  of  the  skin.  When  a  very  marked 
effect  is  desired  the  flap  to  be  removed  is  given  the  shape  as 
represented  at  the  right  of  the  figure.  I  have  found  this  proceed- 
ing extremely  satisfactory,  and  its  result,  as  a  rule,  permanent. 

All  the  foregoing,  and  other  such  measures,  produce  a  good 
result  at  the  time,  but  are  sometimes  followed  by  recurrence  of 
the  entropium.  Hotz*  believes  the  cause  of  this  to  be,  that  the 
cicatrix,  be  it  dermic  or  dermo-muscular,  upon  which  the  result 
depends,  has  no  point  d'ajypui;  and,  consequently,  while  it  may 
draw  the  eyelid  out,  it  is  just  as  liable  to  draw  the  skin  of  the 
cheek  up,  and  thus  neutralize  its  desired  effect.  He  proposes 
the  following  ingenious  operation : — 

Hotzs  Ojyeration. — A  horn  spatula  is  inserted  under  the  lid, 
and  then,  at  4  to  6  mm.  below  the  margin  of  the  latter,  a  hori- 
zontal incision  is  made  through  the  skin  from  the  inner  to  the 

outer  end  of  the  lid.  This  in- 
cision is  at  the  boundary  be- 
tween the  palpebral  and  orbital 
portions  of  the  orbicular  muscle, 
and  just  over  the  lower  margin 
of  the  tarsus.  An  assistant 
then  draws  the  upper  edge  (Fig. 
76,  a)  of  the  wound  upward 
with  a  forceps,  while  the  sur- 
geon draws  the  lower  edge  (b) 
downward,  in  this  way  expos- 
ing and  stretching  the  orbicular 
muscle.  A  few  strokes  of  the  knife  in  the  direction  of  the  inci- 
sion are  now  suflBcient  to  separate  the  palpebral  portion  (/)  of 


Fig.  7 


*Klin.  Monatsbl.f.  Augenhk.,  1880,  p.  149. 


THE   EYELIDS.  165 

the  muscle  from  the  orbital  portion  (^;),  and  to  lay  bare  the 
lower  edge  of  the  tarsus  (t),  which  has  a  yellowish  tendinous 
appearance.  That  part  of  the  palpebral  portion  of  the  muscle 
which  covered  the  lower  edge  of  the  tarsus,  and  which  was 
drawn  up  with  the  palpebral  edge  of  the  first  incision,  is  now 
removed  with  forceps  and  scissors,  to  the  extent  of  about  2  mm. 
in  width,  through  the  whole  length  of  the  lid.  All  such  muscu- 
lar fibres,  also,  which  may  still  adhere  to  the  lower  third  of  the 
tarsus  must  be  carefully  cleaned  off,  and  now  the  palpebral  skin 
may  be  brought  into  union  with  the  tarsus.  Four  sutures  are 
generally  applied  about  5  mm.  apart.  The  needle  is  passed 
through  the  palpebral  skin,  close  to  the  margin  of  the  wound 
(at  a).  The  bare  tarsal  edge  is  then  seized  in  the  forceps,  the 
needle  placed  perpendicularly  on  it  (at  d),  and  carried  through 
it  by  a  short  downward  curve,  until  its  point  appears  (at  c) 
below  the  tarsus  in  the  tarso-orbital  fascia  (/).  The  needle  is 
now  passed  out  through  the  lower  edge  of  the  incision  (at  b), 
care  being  taken  that  none  of  the  fibres  of  the  orbital  portion  of 
the  muscle  are  included  in  the  suture.  Upon  the  suture  being 
tightly  closed,  the  edges  of  the  skin  wound  are  drawn  into  the 
tarsus,  and  become  adherent  to  it.  The  sutures  may  be  removed 
about  the  third  day.  If  the  first  incision  be  placed  too  far  from 
the  margin  of  the  lid,  there  will  be  no  result,  as  the  traction 
upon  the  palpebral  skin  will  be  too  slight.  If  the  incision  be 
placed  too  close  to  the  margin,  the  traction  may  be  so  great  as  to 
interfere  with  the  union  of  the  skin  and  tarsus.  In  this  operation 
the  tarsus  affords  the  fulcrum,  which  Hotz  thinks  is  wanting  in 
other  methods.  The  tarsus  of  the  lower  lid  is  often  very  little 
developed,  and  may  be  difficult  to  find. 

Ectropium  or  Eversion  of  the  Eyelid. — Of  this  there  are  two 
chief  kinds:  1.  Muscular,  or  Spastic;  2.  Cicatricial. 

Muscular  Ectropium  may  be  caused  by  oedema  of  the  con- 
junctiva, which  everts  the  edge  of  the  eyelid,  and  this  eversion  is 
increased,  and  encouraged,  by  spasm  of  the  palpebral  portion  of 
the  orbicular  muscle,  so  that  the  name  palpebral  paraphimosis  has 
been  given  to  the  condition.     In  the  recent  stage  it  may  generally 


166  DISEASES   OF   THE   EYE. 

be  remedied  by  a  properly  applied  bandage,  combined  with  the 
suitable  conjunctival  measures.  In  chronic  cases  Snellen's 
sutures  (vide  infra)  may  be  required. 

Muscular  ectropium  is  often  seen  in  old  people,  and  is  then 
given  the  name  of  Senile  Ectropium.  Here  it  is  due  to  atrophy 
of  the  palpebral  portion  of  the  orbicularis,  and  relaxation  of  the 
skin  of  the  face.  When  these  have  resulted  in  slight  eversion 
of  the  inferior  puuctum,  a  flowing  of  tears  is  produced,  causing 
excoriations  of  the  skin  and  edge  of  the  lid,  which  then,  in  their 
turn,  increase  the  tendency  to  ectropium.  If  the  condition  be 
not  extreme,  with  secondary  changes  in  the  conjunctiva,  slitting 
up  of  the  canaliculus,  with  the  use  of  a  boracic  ointment  for 
the  lids  and  mild  astringents  for  the  conjunctiva,  will  give  much 
relief.  In  pronounced  cases  a  more  active  treatment  of  the  con- 
junctiva, and  the  performance  of  tarsorraphy,  the  latter  preceded 
by  the  application  of  Snellen's  sutures,  are  demanded.  Muscular 
ectropium  is  also  caused  by  paralysis  of  the  orbicular  muscle. 

Snellen's  Sutures. — A  silk  ligature  is  threaded  at  either  end  with 
a  needle  of  moderate  size  and  curve.  The  point  of  one  of  these 
needles  is  passed  into  the  prominent  point  of  the  exposed  and 
everted  conjunctiva,  and  brought  out  through  the  skin  2  cm. 
below  the  edge  of  the  lower  lid.  The  other  needle  is  entered  in 
the  same  way,  5  mm.  from  the  first,  and  made  to  take  a  nearly 
parallel  course,  the  points  of  exit  on  the  cheek  being  1  cm.  apart. 
Equal  traction  is  applied  to  each  end  of  the  suture,  while  the  lid 
is  assisted  into  its  place  by  the  finger.  The  suture  is  tied  on  the 
cheek,  a  small  roll  of  sticking  plaster  having  been  inserted  under 
it,  to  protect  the  skin  from  being  cut.  Two,  or  even  three,  such 
sutures  may  be  required. 

Argyll  Robertson' s  Operation  "^  has  been  designed  for  those  cases 
of  ectropium  which  result  from  long-continued  chronic  inflam- 
mation of  the  conjunctiva  of  the  lower  lid.  He  thinks  the 
difficulty  in  severe  cases  of  this  kind  depends  upon  the  abnormal 

*  Edinburgh  Clinical  and  Pathological  Journal,  December,  1883;  and 
Ophthal.  Rev.,  February,  1884. 


THE   EYELIDS. 


167 


curvature  which  is  gradually  acquired  by  the  tarsus.  The  fol- 
lowing is  his  description  of  the  operation,  from  which  he  has 
obtained  satisfactory  results  : — 

The  materials  required  are — 

1.  A  piece  of  thin  sheet-lead  about  1  inch  long  and  t  inch 
broad,  rounded  at  its  extremities,  and  with  its  cut  margins 
smoothed.  This  piece  of  lead  must  be  bent  with  the  fingers  to  a 
curvature  corresponding  to  that  of  the  eyeball. 


Fig. 


2.  A  waxed  silk  ligature  about  15  inches  long,  to  either  ex- 
tremity of  which  a  long  moderately  curved  needle  is  attached. 

3.  A  piece  of  fine  india-rubber  tubing  (the  thickness  of  a  fine 
drainage-tube). 

The  operation  is  performed  by  perforating  the  whole  thickness 
of  the  lid- with  one  of  the  needles  at  a  point  (h,  Fig.  77)  one  line 
from  its  ciliary  margin,  and  a  quarter  of  an   inch  to  the  outer 


168  DISEASES   OF   THE   EYE. 

side  of  the  centre  of  the  lid.  The  needle  having  been  drawn 
through  (at  a),  is  passed  directly  downward  over  the  conjunc- 
tival surface  of  the  lid,  till  it  meets  the  fold  of  conjunctiva 
reflected  from  the  lid  on  to  the  globe,  through  which  the  needle 
is  thrust — the  point  being  directed  slightly  forward — and 
pushed  steadily  downward  under  the  skin  of  the  cheek,  until  a 
point  (d)  is  reached  about  1  inch  or  It  inch  below  the  edge  of 
the  lid,  when  the  needle  is  caused  to  emerge,  and  the  ligature  is 
drawn  through.  The  other  needle  is,  in  like  manner,  thrust 
through  the  edge  of  the  lid  at  a  corresponding  point  {b')  a 
quarter  of  an  inch  to  the  inner  side  of  the  middle  of  the  lid,  then 
passed  over  the  conjunctival  surface  of  the  lid,  through  the 
oculo-palpebral  fold  of  conjunctiva,  and  downward  under  the 
skin,  till  the  point  emerges  at  a  spot  (cV)  a  quarter  of  an  inch 
outward  from  the  point  of  emergence  of  the  first  needle  {d). 
The  ligature  is  kept  slack,  or  is  slackened  so  as  to  permit  of  the 
piece  of  lead  being  introduced  under  the  loops  of  the  ligature 
that  pass  over  the  conjunctival  surface  of  the  lid,  and  of  the 
piece  of  india-rubber  tubing  (c)  being  slipped  under  the  loop  at 
the  edge  of  the  lid  (between  b  and  6').  The  free  ends  of  the 
ligature  are  now  drawn  tight,  and  tied  moderately  tightly  over 
a  lower  part  of  the  india-rubber  tube.  The  excess  of  india- 
rubber  tube  is  cut  ofli — about  a  quarter  of  an  inch  beyond  the 
ligature — and  the  operation  is  complete. 

The  result  of  the  procedure  is,  that  the  edge  of  the  lid  is 
made  to  revolve  inward  over  the  upper  edge  of  the  piece  of 
lead,  while  the  tarsus  is  caused  to  mould  itself  to  the  curve  of 
the  lead,  and  the  eyelid  at  once  occupies  its  normal  position.  A 
certain  amount  of  redness  and  oedema  of  the  lid  follows  the 
operation,  and  suppuration  occurs  in  the  track  of  the  ligature  ; 
but,  as  the  india-rubber  tube  yields  somewhat  to  the  tension 
on  the  ligature,  the  irritation  resulting  is  moderate,  so  that 
the  apparatus  need  not  be  removed  for  five,  six,  or  seven  days, 
by  which  time  the  tarsus  has  become  pretty  well  fixed  in  its 
new  curvature.     A  slight  relapse  may  occur  when   the  appa- 


THE    EYELIDS. 


169 


J^^arton   Jones's    Operation 
circumscribed    by    a    V-shapet 


ratus  is  removed,  but  this  is  readily  amenable  to  treatment  by 

astrintrent  applications. 
^  '  The   suppuration    occurring 

in  the  tracks  of  the  ligature 
leads  to  cicatricial  formation, 
which  appears  to  impart  a 
degree  of  rigidity  to  the  lid, 
which  helps  to  keep  it  in  its 
new  position. 

Cicatricial  Ectropium  is 
caused  by  scars  from  wounds 
or  burns,  or  from  caries  of  the 
orbit,  and  can  only  be  cured 
by  operation, 
is  as  follows :  The  cicatrix  is 
incision  (Fig.  78),  and  the 
skin  made  thoroughly  movable  in  its  neighborhood.  The 
edges  of  the  wound  are  now  brought  together  so  as  to  form 
a  Y  (Fig.  79). 

ArWs  Operation,  for  cases  ^^^-  '^  ^^'  ^''^''''^' 

due  to  caries  of  the  margin 
of  the  orbit. — If  the  cicatrix 
be  situated   at  e  (Fig.  80), 
the  incisions  at  a  b  and  h  c 
are  made  through  the  skin 
and  muscle,  so  that  an  acute, 
or  at  most  a  right,  angle  is 
formed  at  b.      The  margin 
of  the  lid  from  c  to  d  is  ex- 
cised.    The  cicatrix  is  com- 
pletely undermined,  and  the 
triangle  dissected  up  from  b  to  the  margin  of  the  tarsus,  so  that- 
the  lid  can  be  readily  put  into  its  position,  and  the  edge  c  b  of 
the  flap  united  to  d  c.     The  size  of  the  exposed  surface  on  the 
cheek  can,   according    to  Arlt,  be   diminished  by  drawing  its 
15 


170 


DISEASES    OF   THE    EYE. 


Fig.  so  {de  Wecker). 


edges  together  after  the  manner  of  a  hare-lip,  but  possibly  the 

transplantation  of  a  piece  of  skin 
from  the  arm  to  fill  the  gap  might 
be  a  better  plan. 

The  foregoing  and  similar  opera- 
tions are  diflScult  or  impossible  in 
many  cases,  where  there  has  been 
great  destruction  of  the  skin  of  the 
eyelids  and  surrounding  parts  by 
burns,  ulcers,  etc.,  and,  at  best,  the 
deformity  is  liable  to  recur.  Trans- 
plantation of  skin  from  distant 
parts  is  in  these  cases  a  more  promising  proceeding.  A  descrip- 
tion of  the  method  is  given  in  the  next  paragraph  but 
one. 

Ankyloblepharon  (ay/.uArj,  a  i^tring ;  ^U(fo.f)<r^^  an  eyelid)  is  a 
uniting  of  the  upper  and  lower  eyelids  along  their  margins.  It 
may  be  partial  or  complete,  and  often  goes  with  symblepharon. 
Like  the  latter,  it  is  usually  caused  by  burns  and  ulcers. 

The  condition  can  only  be  relieved  by  operation,  of  which  the 
result  is  often  unsatisfactory,  owing  to  the  difficulty  of  prevent- 
ing reunion  taking  place.  To  avert  this  it  is  always  necessary  to 
cover  the  wounded  surface  with  conjunctiva  or  skin. 

The  Restoration  of  an  Eyelid. — It  is  an  extremely  rare  event 
for  the  whole  substance  of  one  or  both  eyelids  to  be  destroyed 
by  lupus  or  other  ulceration,  or  by  accidents  which  do  not  at 
the  same  time  injure  the  eyeball  seriously.  In  this  rare  event, 
the  eyeball,  especially  if  the  upper  lid  be  destroyed,  is  exposed, 
the  patient  is  subject  to  extreme  discomfort,  and,  owing  to  ulcer- 
ation of  the  cornea,  the  eye  is  ultimately  lost.  The  formation 
of  an  eyelid  from  the  skin  of  the  forehead  or  cheek  in  these 
cases  is  a  most  disappointing  proceeding,  and  one  the  descrip- 
tion of  which  does  not,  I  consider,  come  within  the  scope  of  this 
book.  In  fact,  my  own  feeling,  in  such  a  case,  would  be  to  recom- 
mend enucleation  of  the  eyeball,  provided  the  fellow  eye  were 


THE    EYELIDS.  171 

good,  rather  than  propose  a  plastic  operation,  which,  at  the  best, 
would  give  but  an  imperfect  result. 

But,  fortunately,  the  class  of  cases  with  which  we  commonly 
meet  are  essentially  different  in  their  nature ;  for  in  them  the 
whole  thickness  of  the  eyelid  is  not  destroyed.  They  are  usually 
the  result  of  burns  (epileptics  and  children  falling  in  the  fire) 
and  scalds,  which  only  destroy  the  integument  of  one  or  both 
eyelids.  A  granulating  surface  replaces  the  skin,  and,  when 
healing  commences,  the  shriukiug  draws  the  free  margin  of  the 
upper  eyelid  up  toward  the  eyebrow,  and  that  of  the  lower  lid 
down  toward  the  cheek,  while  the  conjunctival  surface  of  the 
eyelids  becomes  everted  and  the  cornea  exposed,  as  the  eyelids 
cannot  now  be  closed.  We  have  a  satisfactory  method  for  deal- 
ing with  these  cases. 

In  the  first  place,  the  eyelid — let  us  suppose  it  to  be  the  upper 
eyelid — is  dissected  down  into  its  place  to  the  utmost  limit,  so 
that  the  most  extensive  raw  surface  possible  may  be  obtained. 
The  margin  of  the  lid  is  now  fastened  to  the  cheek  with  three 
points  of  suture.  A  portion  of  skin,  one-third  larger  (to  allow 
for  shrinkage)  than  the  raw  surface  of  the  eyelid,  is  then  taken 
from  the  inside  of  the  arm,  and,  after  being  freed  of  its  subcuta- 
neous fat,  is  laid  upon  the  raw  surface  and  fastened  to  it  by  a 
large  number  of  fine  sutures  around  the  margin.  A  non-irritating 
antiseptic  dressing  is  applied,  and  the  graft  usually  heals  on  in 
the  course  of  a  few  days.  This  method  of  grafting  was  introduced 
by  Wolfe  and  Lefort. 

The  flap  sometimes  becomes  separated  from  the  wounded  sur- 
face by  oozing  of  blood  or  serum  from  the  wound  and  then 
sloughs.  To  prevent  this,  Wickerkiewicz  has  employed  second- 
ary transplantation  with  satisfactory  results.  The  flap  is 
applied  to  the  wounded  surface  from  two  to  five  days  after  the 
latter  has  been  prepared,  while  during  the  interval  the  wounded 
surface  has  been  protected  with  moist  antiseptic  dressings. 
He  states  that  union  by  first  intention  occurs  readily  by  this 
method. 

In  this  operation  it  is  most  important  to  preserve  and  utilize 


172  DISEASES   OF   THE   EYE. 

any  part  of  the  eyelid  which  remains,  especially  its  ciliary 
border  with  the  eyelashes. 

Injuries  of  the  Eyelids. — All  kinds  of  injuries  of  the  eyelids — 
contusions,  incisions,  burns,  etc. — are  common. 

In  consequence  of  the  looseness  of  the  integument,  oedema  and 
ecchymosis,  one  or  both,  are  often  seen  in  a  marked  degree  as 
the  result  even  of  slight  injuries. 

Owing  to  the  direction  of  the  fibres  of  the  orbicularis,  an 
incised  wound  of  the  eyelid,  if  in  the  vertical  direction,  will 
gape,  while  a  similar  wound  in  the  horizontal  direction  will  not 
do  so.  Hence  the  scar  left  after  the  former  wound  is  apt  to  be 
very  visible,  but  that  after  the  latter  may  be  almost  imper- 
ceptible. If  the  eyelid  be  divided  vertically  in  its  entire  thick- 
ness, unless  union  by  first  intention  can  be  obtained,  a  deep 
furrow  is  left  in  the  eyelid,  and  perhaps  at  its  margin  an 
unsightly  coloboma. 

Emphysema  of -the  eyelids  is  sometimes  seen  after  a  blow  on 
the  eye,  and  is  a  sign  of  fracture  of  the  orbit  with  a  communica- 
tion between  the  subcutaneous  connective  tissue  of  the  eyelids 
and  the  nose,  the  ethmoid  sinus,  the  frontal  sinus,  or  the  antrum 
of  Highmore.  An  emphysematous  lid  is  swollen,  and  soft  and 
crepitating  to  the  touch. 

Ecchymosis  of  the  lower  lid,  usually  with  ecchymosis  of  the 
lower  conjunctiva,  after  falls  or  blows  on  the  head,  is  a  sign  of 
fracture  of  the  base  of  the  skull,  the  blood  making  its  way  along 
the  floor  of  the  orbit. 

Simple  ecchymosis  of  the  eyelids  from  blows,  commonly  known 
as  "  Black  Eye,"  never  gives  rise  to  further  complication.  It 
requires  some  fourteen  days  or  more,  according  to  the  quantity 
of  blood  extravasated,  before  the  eye  recovers  its  normal  appear- 
ance. 

Treatment. — Injuries  of  the  eyelids,  of  whatever  kind,  are, 
of  course,  treated  upon  general  surgical  principles.  Incised 
wounds  should  be  carefully  and  neatly  drawn  together  with 
sutures  as  soon  after  the  injury  as  possible  and  with  antiseptic 
precautions.     Emphysema  may  be  assisted  in  its  absorption  by 


THE    EYELIDS.  173 

the  application  of  a  rather  tight  bandage,  and  directions  should 
be  given  to  the  patient  to  blow  his  nose  as  gently  as  possible,  so 
as  to  avoid  recurrence  of  the  emphysema. 

Epicanthus  is  a  congenital  deformity,  usually  binocular,  which 
in  the  most  pronounced  cases  consists  in  partial  paralysis  of  the 
levator  palpebrie  (ptosis)  and  of  the  rectus  superior,  with  a 
narrow  palpebral  fissure,  and  a  fold  of  integument  at  the  inner 
canthus  concealing  the  caruncle  from  view,  and  giving  the 
appearance  of  great  breadth  to  the  bridge  of  the  nose.  The 
term  is  also  used  for  cases  in  which  the  integumental  fold  at  the 
inner  canthus  is  the  only  abnormal  condition,  and  this  deformity 
can  be  somewhat  diminished  by  the  removal  of  an  oval  piece  of 
skin  from  the  bridge  of  the  nose,  its  long  axis  vertical  and  its 
width  varying  according  to  the  effect  required.  The  margins  of 
the  wound  being  brought  together,  the  abnormal  folds  are 
diminished  in  width. 

Congenital  Coloboma  of  the  upper  lid,  and  even  congenital 
absence  of  the  eyelids,  have  been  occasionally  observed. 


CHAPTER  VII. 
DISEASES  OP  THE  LACHRYMAL-  APPARATUS. 

Malposition  of  the  Pimctum  Lachrymale.f — Inversion  of  the 
puuctum  accompanies  entropium  of  the  lower  eyelid,  while  ever- 
siou  of  it  is  present  with  ectropium  of  the  lid.  A  slight  eversion, 
quite  sufficient  to  cause  epiphora,  may  exist  without  any  marked 
ectropium  of  the  lid,  and  it  is  these  cases  which  more  properly 
belong  to  this  chapter.  They  are  the  result  generally  of  some 
chronic,  although  it  may  be  slight,  skin  affection  of  the  lower  lid, 
which  draws  the  inner  end  of  the  latter  a  little  away  from  the 
eyeball. 

The  prominent  symptom  of  this,  and  of  all  the  following  lachry- 
mal affections,  is  Epiphora  {liziipopd  oa/.pou)'^,  a  sudden  hurst  of 
tears),  a  flowing  of  tears  over  the  cheek. 

Stenosis  and  Complete  Occlusion  of  the  Punctum  Lachrymale. 
— Either  of  these  conditions  may  result  from  conjunctivitis  or 
from  marginal  blepharitis,  although  they  may  not  appear  for  a 
length  of  time  after  those  affections  have  passed  away,  and  the 
original  affection  may  have  been  so  slight  as  to  have  escaped  the 
observation  of  the  patient.  In  stenosis,  the  size  of  the  punctum 
may  become  so  extremely  minute,  that  even  the  normal  flow  of 
tears  is  too  great  to  make  its  way  through  it.  Complete  occlu- 
sion is,  probably,  only  a  more  advanced  stage  of  stenosis. 

The  Treatment,  in  cases  of  eversion  of  the  punctum,  as  well  as 
in  stenosis  and  in  complete  occlusion,  is  similar,  namely,  the 
opening  up  of  the  punctum  and  its  conversion  into  a  slit.  This 
is  done  with  a  Weber's  knife  (Fig.  81),  the  probe-point  of  which 


*  Lachryma,  a  tear. 

fin  this  chapter,  and  elsewhere  in  the  book,  the  terms  "punctum 
lachrymale"  and  "  canaliculus"  refer  to  the  inferior  passage,  unless  it 
be  otherwise  expressly  stated. 

174 


^ 


THE    LYCHRYMAL    APPARATUS.  175 

is  passed  into  the  punctum  in  cases  of  eversion,  forced  into  the 
small  opening  in  cases  of  stenosis,  or  forced  through  the  Yig.  81. 
usually  thin  covering  of  the  punctum  in  cases  of  occlu- 
sion. In  doing  this,  the  lower  lid  should  be  stretched 
tightly  by  a  finger  of  the  surgeon's  left  hand  placed  near 
the  external  cauthus.  The  edge  of  the  knife  being  now 
directed  toward  the  eyeball,  the  instrument  is  pushed 
on  a  little  into  the  canaliculus,  until  2  mm.  of  the  latter 
have  been  opened  up,  and  it  is  then  withdrawn.  If  the 
edge  of  the  knife  be  directed  outward  in  this  proceed- 
ing, the  incision  comes  to  lie  on  the  outer  edge  of  the 
intermarginal  portion  of  the  lid,  and  not  in  contact  with 
the  eyeball ;  consequently,  the  tears  are  not  carried 
away,  and  the  disfigurement  produced  is  considerable. 
A  slitting  up  of  the  whole,  or  the  greater  part,  of  the 
canaliculus  in  these  cases  is  unnecessary,  and  interferes 
with  the  physiological  action  of  the  tear  passage.  For 
two  or  three  days  after  the  little  operation  it  is  neces- 
sary to  pass  a  probe  along  the  portion  of  the  canaliculus 
which  has  been  slit  up,  to  prevent  union  taking  place. 

Obstruction  of  the  Canaliculus. — The  canaliculus  may 
be  diminished  in  its  calibre  or  entirely  closed  by  con- 
traction, the  result  of  inflammation  which  had  extended 
to  it  from  the  conjunctival  sac.  It  is  not  possible  to 
diagnose  the  presence  of  either  of  these  conditions, 
which  may  be  associated  with  stenosis  or  occlusion  of 
the  punctum  lachrymale,  except  by  the  introduction  of  a 
very  fine  probe  into  the  canaliculus.  The  passage  may 
also  be  obstructed  by  an  eyelash,  a  chalky  deposit,  or  a 
mass  of  leptothrix. 

Treatment. — Where  there  is  merely  diminution  in  the 
calibre  of  the  passage,  the  introduction  of  probes,  in- 
creasing in  size,  is  frequently  sufficient  to  effect  a  cure. 
Dilators,  on  the  same  principle  as  Holt's  instrument  for 
the  dilatation  of  urethral  strictures,  have  been  era- 
ployed.     If  dilatation  fail,  recourse  must  be  had  to  slit- 


176  DISEASES    OF    THE    EYE. 

ting  up  the  canaliculus;  but  if  it  can  possibly  be  avoided — that 
is,  if  a  less  extended  opening  will  answer — the  passage  should  not 
be  slit  up  in  its  entire  length.  At  least  3  ram.  of  its  median  end 
ought  to  be  left  intact,  as  otherwise  regurgitation  of  tears  from 
the  lachrymal  sac  is  liable  to  trouble  the  patient  ever  afterward. 
If  the  canaliculus  be  completely  closed  by  adhesions,  so  that  a 
fine  probe  cannot  be  pushed  through  it,  it  becomes  necessary  to 
rip  it  up  with  the  point  of  any  small  knife,  following  the  known 
course  of  the  passage  from  the  outside.  If  the  canaliculus  be 
closed  as  far  as  the  opening  into  the  sac,  or  if  only  at  that  point, 
the  obstruction  must  be  pierced  with  the  point  of  a  fine  knife. 
A  great  difficulty  in  all  these  cases  is  to  keep  the  passage  patent 
when  once  formed.  A  plan  which  afi'ords  tolerable  certainty  of 
this  is  the  frequent  passage  of  probes  into  the  sac,  until  the 
tendency  to  closure  seems  to  have  ceased  ;  but,  even  under  favor- 
able conditions,  recurrences  of  the  closure  are  apt  to  occur.  In 
order  to  cure  this  condition,  and  in  the  hopes  of  doing  so  per- 
manently, Dr.  W.  E.  Steavenson  and  Mr.  Walter  Jessop*  have 
employed  electrolysis,  which  they  apply  to  the  canaliculus  by 
means  of  a  platinum  probe  fitted  in  a  handle  and  connected  with 
the  negative  pole  of  a  Stohrer's  battery.  A  flat  electrode  con- 
nected with  the  positive  pole  is  placed  on  the  back  of  the  neck. 
A  current  of  two  to  four  milliaraperes  is  sufficient,  and  the  opera- 
tion lasts  thirty  seconds.  By  this  procedure  the  canaliculus  is 
rendered  wide  enough,  but  time  has  yet  to  show  whether  recur- 
rence of  the  stricture  is  less  frequent  than  after  treatment  by 
other  methods. 

Stricture  of  the  Nasal  Duct  is  usually  the  result  of  swell- 
ing of  its  mucous  membrane  in  catarrhal  attacks,  or  of  mem- 
branous or  cicatricial  contraction  resulting  from  long-continued 
catarrh.  It  also  occurs  in  consequence  of  disease  of  the  bones  of 
the  nose,  e.  //.,  in  syphilis,  acquired  or  congenital,  and  from  blows 
which  fracture  the  bridge  of  the  nose. 

Treaiment. — Bony   stricture    may   be   regarded    as  incurable. 

*  Brit.  Med.  Journal,  December  24lh,  1887. 


THE    LACHRYMAL    APPARATUS.  177 

Stricture  due  to  inflammatory  swelling  of  the  mucous  mem- 
brane, also  membranous  or  cicatricial  strictures,  are  best 
treated  by  means  of  probes,  in  the  manner  proposed  by  Sir 
William  Bowman.  The  inferior  canaliculus  is  slit  up  to  a 
slight  extent,  so  as  to  admit  the  point  of  one  of  Bowman's 
smallest  probes,  which  is  given  a  curve  to  suit  that  of  the  nasal 
duct.  With  the  fingers  of  the  left  hand  the  surgeon  stretches 
the  lower  lid,  and,  entering  the  probe  into  the  canaliculus, 
pushes  it  gently  along  its  floor  until  the  point  reaches  the 
lachrymal  bone  forming  the  posterial  wall  of  the  sac.  The  point 
being  kept  pressed  against  this  bone,  the  direction  of  the  probe 
is  now  altered  by  carrying  its  free  end  upward  toward  the  bridge 
of  the  nose,  until  the  point  at  the  other  end,  in  the  lachrymal  sac, 
is  directed  toward  or  aimed  at  the  sulcus  between  the  ala  of 
the  nose  and  the  cheek.  The  probe  then  is  in  a  position  cor- 
responding to  the  prolonged  axis  of  the  nasal  duct,  down  which 
it  is  pushed  with  a  slow  and  gentle  motion.  Any  obstacles  met 
with  on  the  way  are  overcome,  if  possible,  by  an  increase  of  the 
pressure,  but  if  at  any  part  of  the  proceeding  much  difficulty  be 
encountered,  rather  than  that  any  violence  be  used,  all  further 
manipulation  should  be  postponed  to  another  day ;  and  it  will 
often  be  found  that,  at  the  second  or  third  visit,  the  probe  is 
passed  with  comparative  ease.  Thicker  probes  are  gradually 
introduced  at  successive  sittings,  until  the  largest  size  has  been 
reached. 

The  most  common  seats  for  stricture  of  the  nasal  duct  are  at 
its  entrance  into  the  sac,  where  it  is  narrowest,  and  at  its  lower 
end,  where  it  is  most  exposed  to  catarrhal  processes  in  the 
nostril. 

Where  there  is  reason  to  think  that  the  stricture  is  due  to 
chronic  catarrhal  swelling  of  the  lining  mucous  membrane  of  the 
duct,  astringent  injections  into  the  canal,  in  addition  to  the 
probing,  are  of  use. 

Otto  Becker  uses  very  fine  probes,  which  he  passes  by  the 
upper  canaliculus.  Weber's  probes  are  conical  and  of  very 
large  calibre  at  their  thickest  part.     Their  inventor  passes  them 


178  DISEASES   OF   THE    EYE. 

by  the  superior  canaliculus,  but  many  other  surgeons  pass  them 
by  the  lower.  I  do  not  employ  these  probes,  because,  when 
passed  into  the  nasal  duct,  their  thickest  part,  which  is  3  to  4 
mm.  in  diameter,  corresponds  with  the  upper  end  of  the  duct, 
which  is  its  narrowest  part,  being  only  3  mm.  in  diameter; 
consequently,  the  probe  becomes  more  or  less  impacted  at  this 
place  at  each  operation,  and  is  apt  ultimately  to  give  rise  there 
to  hypertrophy  of  the  periosteum  and  finally  to  stricture ;  so 
that  while  the  immediate  effect  of  their  use  is  good,  the  ultimate 
result  is  often  the  opposite.  When  used  by  the  inferior  canalic- 
ulus, their  size  makes  it  necessary  to  slit  that  passage  in  its 
entire  length,  and  the  entrance  of  the  passage  into  the  sac  must 
be  enormously  dilated  by  so  large  an  instrument,  both  of  which 
circumstances  are  most  undesirable. 

To  prevent  closure  of  the  duct  when  once  made  free,  Dr. 
Arthur  Benson  (Dublin)  advocates  the  use  of  leaden  styles, 
removable  by  the  patient.  He  first  divides  the  canaliculus,  by 
preference  the  upper  one,  and  dilates  the  stricture  with  probes 
in  the  ordinary  way,  and  then  introduces  into  the  duct  a  piece 
of  leaden  wire  1.5  mm.  to  2  mm.  in  diameter,  cut  to  length  and 
smoothed  ofi"  at  the  ends.  The  upper  end  is  curved  so  as  to  lie 
out  on  the  cheek.  This  style  is  at  first  removed  daily  and  the 
duct  syringed,  until  any  existing  inflammation  and  discharge 
have  almost  ceased.  The  intervals  are  then  increased,  and 
as  soon  as  practicable  the  patient  is  taught  to  remove  the  style 
and  to  replace  it  himself.  When  he  is  able  to  do  this  easily,  he 
is  directed  to  leave  the  style  out  for  some  hours  each  day,  and 
finally  to  wear  it  only  at  night. 

Stilling  has  proposed  an  operation,  which  he  calls  strictur- 
otomy,  for  the  cure  of  membranous  obstructions  in  the  duct. 
Having  slit  up  the  canaliculus,  and  ascertained  with  a  probe 
the  position  of  the  stricture.  Stilling  passes  his  knife,  with  the 
cutting  edge  directed  forward,  down  the  duct  and  through  the 
stricture;  he  then  withdraws  it  a  little,  turns  the  edge  in 
another  direction,  and  pushes  it  again  through  the  stricture,  and 
performs  this  manoeuvre  a  third  time  before  removing  the  knife. 


THE   LACHRYMAL   APPARATUS.  179 

On  subsequent  days  large  probes  are  passed.  This  method  has 
never  gained  much  popularity. 

The  most  favorable  cases  of  stricture  for  cure  are  those  due 
to  inflammatory  swelling  of  the  mucous  membrane,  and  next  in 
order  come  those  caused  by  membranous  or  cicatricial  con- 
traction, while  those  due  to  bony  obstructions  must,  as  already 
stated,  be  regarded  as  incurable. 

Now  and  then  cases  of  persistent  lachrymation  will  be  met  with 
in  which  the  nasal  duct  aud  the  rest  of  the  lachrymal  apparatus 
are  in  perfect  order.  These  are  often  due  to  a  catarrhal  affec- 
tion of  the  nasal  mucous  membrane,  slightly  involving  the 
very  lowest  extremity  of  the  nasal  duct.  Here  applications 
directed  toward  relief  of  the  nasal  affection  are  indicated. 

Blennorrhoea  of  the  Lachrymal  Sac  is  commonly  caused,  in  the 
first  instance,  by  stricture  of  the  nasal  duct.  In  consequence 
of  this  stricture,  the  tears  and  the  normal  mucous  secretion  of 
the  lining  membrane  of  the  sac  are  retained  there  and  offer 
favorable  conditions  for  the  development  of  the  micro-organ- 
isms, which  are  constantly  present  on  the  surface  of  the  eye,  and 
are  carried  into  the  lachrymal  sac  by  the  tears.  These  decom- 
posing contents  of  the  sac,  then,  set  up  inflammation  of  its 
mucous  membrane,  with  discharge  of  a  muco-purulent  nature. 

But  one  not  seldom  comes  across  cases  of  lachrymal  blen- 
norrhoea where,  upon  examination,  no  stricture  of  the  nasal  duct 
is  found.  Yet  in  many  of  these  cases  there  has  been  a  stricture 
due  merely  to  catarrhal  swelling  of  the  lining  membrane  of  the 
duct,  which  swelling  has  subsided  in  the  course  of  time  without 
treatment,  aud  the  duct  has  then  again  become  free,  while  still 
the  lachrymal  blennorrhoea,  to  which  the  stricture  gave  rise,  con- 
tinues. It  is  very  probable,  however,  that  lachrymal  blennorrhoea 
may  occasionally  come  on  where  there  has  never  been  a  stricture 
of  the  nasal  duct,  and  merely  as  an  extension  of  catarrh  from 
the  nostrils,  especially  in  cases  of  ozsena,  or  as  an  extension  of 
catarrh  from  the  conjunctiva. 

Symptoms. — The  patients  usually  complain  of  nothing  more 
than   epiphora.      Those  who  are  more  observant  of  themselves 


180  DISEASES   OF   THE   EYE. 

may  have  noticed  a  swelling,  which  we  call  a  "  lachrymal  tumor," 
or  "mucocele,"  in  the  region  of  the  lachrymal  sac,  and,  also,  that 
the  conjunctival  sac,  especially  when  the  swelling  is  pressed 
upon,  becomes,  now  and  then,  more  or  less  filled  with  a  some- 
what thick  and  opaque  discharge  which  obscures  the  sight 
until  wiped  away.  Occasionally,  there  is  no  lachrymal  tumor, 
for  the  contents  of  the  sac  may  not  be  copious  enough  to  bulge 
it  out. 

In  order  to  ascertain  in  each  case  of  epiphora  whether  or  not 
lachrymal  bleunorrho^a  be  present,  the  surgeon  presses  with  his 
finger  over  the  lachrymal  sac,  when,  if  there  be  blennorrhoea,  the 
discharge  will  be  evacuated  through  the  puncta  into  the  con- 
junctival sac.  In  those  cases  in  which  there  is  no  longer  a 
stricture  of  the  nasal  duct,  the  discharge  may  pass  downward 
into  the  nose,  and  the  patient  will  feel  it  in  his  nostril,  and  can 
blow  it  out  of  the  latter. 

Conjunctivitis  must  be  regarded,  not  as  the  cause,  but  rather 
as  the  eflfectof  a  lachrymal  blennorrhoea,  by  reason  of  the  decom- 
posing discharge  from  the  sac  making  its  way  into  the  con- 
junctival sac.  Blepharitis,  too,  is  seen  as  a  further  result 
of  irritation  from  the  discharge,  in  old-standing  cases. 

Treatment. — It  is  important,  in  the  first  place,  to  ascertain 
whether  there  be  a  stricture  of  the  nasal  duct,  and  for  this 
purpose  water  should  be  injected  by  means  of  an  Auel's 
syringe  through  the  canaliculus  into  the  duct.  If  the  fluid 
make  its  way  freely  into  the  nose  or  pharynx,  it  may  be  taken 
for  granted  that  the  nasal  duct  is  not  obstructed  ;  but  if,  instead 
of  passing  through — or  only  under  high  pressure — it  distend  the 
lachrymal  tumor  to  a  greater  size,  a  stricture  may  be  assumed. 
If  stricture  of  the  nasal  duct  be  present,  it  must  be  relieved,  or 
all  measures  will  prove  futile.  Should  there  be  no  stricture,  and 
also  before  and  after  any  existing  stricture  has  been  freed,  the 
treatment  consists  in  the  very  frequent  pressing  out  of  the  con- 
tents of  the  sac  by  the  patient,  so  that  no  distention  of  it  may 
occur ;  and  in  this  manoeuvre  he  should  endeavor  to  cause  the 
discharge   to   pass   down  the   nose,  rather   than  into   the   eye ; 


THE   LACHRYMAL   APPARATUS.  181 

while  the  surgeon,  having,  if  necessary,  dilated  the  canaliculus, 
injects  astringent  solutions  (sulphate  of  zinc,  nitrate  of  silver, 
alum,  sulphate  of  copper)  into  the  sac  daily,  to  relieve  the 
catarrh. 

The  caustic  treatment,  recommended  further  on  for  acute 
dacryocystitis,  is  often  of  the  greatest  benefit  in  these  chronic 
cases.  Any  existing  conjunctivitis,  or  nasal  catarrh  should 
be  treated. 

Acute  Dacryocystitis  (^day.pouj,  to  weep  y.o(jz'.<^,  a  bladder). — 
Acute  inflammation  of  the  lachrymal  sac  most  usually  comes  on 
when  chronic  lachrymal  blennorrhoea  is  already  present.  Caries 
of  the  nasal  bones  may  cause  it,  and  it  occurs  idiopathically, 
probably  as  the  result  of  exposure  to  cold. 

The  region  of  the  lachrymal  sac  and  the  surrounding  integument 
become  swollen,  tense,  and  red,  and  these  conditions  often  spread 
to  the  lids,  giving  an  appearance  which  may  be  readily  mistaken 
for  erysipelas  ;  but  the  history  of  the  case,  showing  the  previous 
existence  of  lachrymal  obstruction,  etc.,  will  assist  the  diagnosis. 
Great  pain  accompanies  the  inflammatory  process.  Gradually 
the  region  corresponding  to  the  lachrymal  sac  becomes  the  most 
prominent  one  of  the  swelling,  and  the  abscess,  pointing  there, 
opens.  AVhen  the  pus  has  been  discharged,  the  inflammation 
subsides,  and  the  opening  through  the  skin  may  either  close,  the 
parts  resuming  their  normal  functions,  or  the  opening  may  remain 
as  a  permanent  fistula. 

The  diflTerence  between  chronic  blennorrhoea  of  the  lachrymal 
sac  and  acute  dacryocystitis,  besides  the  fact  that  one  is  a 
chronic  and  the  other  an  acute  inflammatory  process,  is  that 
the  former  process  is  confined  to  the  mucous  membrane  of  the 
sac,  ^vilile  in  the  latter  the  submucous  tissue  is  involved,  with 
phlegmonous  inflammation  as  the  result. 

Treatment. — In  the  early  stages  poultices  and  purgatives 
should  be  employed.  As  soon  as  palpation  of  the  sac  indicates 
the  presence  of  pus,  it  must  be  evacuated.  This  can  be  eflfected 
either  through  the  canaliculus,  by  opening  it  up  to  its  entrance 
into  the  sac,  or  by  an  incision  through  the  integument  over  the 


182  DISEASES   OF   THE    EYE. 

sac.  The  latter  is  the  method  I  prefer,  as  its  admits  of  free  access 
to  the  interior  of  the  sac.  The  day  afterward,  the  walls  of  the 
sac  are  to  be  freely  touched  with  solid  mitigated  nitrate  of  silver ; 
or,  a  plug  of  cotton  wool  soaked  in  a  strong  solution  of  nitrate 
of  silver  may  be  inserted  into  its  cavity  and  left  there  for  some 
hours;  or,  various  astringent  solutions  may  be  injected  into  the 
sac.  The  aim  of  the  treatment,  whatever  it  may  be,  is  to  secure 
a  rapid  return  of  the  mucous  membrane  to  its  normal  condition. 
If  stricture  of  the  nasal  duct  be  present,  it  must  be  treated  pari 
passu.  By  these  means  the  discharge  from  the  sac  is  arrested, 
and  the  external  opening  closes  up. 

If  a  fistula  should  form,  it  may  be  induced  to  close,  in  many 
cases,  by  simply  freeing  an  existing  stricture  of  the  nasal  duct. 
Or,  it  may  be  necessary  to  pare  its  edges  and  bring  them  together 
by  sutures.  Or,  especially  if  there  be  a  long  fistulous  passage, 
the  galvano-cautery,  in  the  form  of  a  platinum  wire,  may  be 
applied  with  advantage. 

Obliteration  of  the  sac  may  have  to  be  brought  about  in  some 
very  chronic  cases,  where  repeated  attacks  of  acute  inflammation 
and  fistula  occur  ;  or,  where  there  is  constant  discharge  and  dis- 
ease of  bone,  and  when  all  other  methods  have  failed  to  relieve 
the  patient.  This  can  be  done  by  the  application  of  a  galvano- 
cautery  to  the  lining  membrane  of  the  sac,  or  by  dissecting  it 
out.  But  I  must  say  that,  in  my  experience,  obliteration  of  the 
lachrymal  sac  is  one  of  the  most  difficult  undertakings  in  ophthal- 
mic surgery. 

Dacryoadenitis  {oay-jioio,  to  weep;  d8rjv,  a  gland)  or  Inflamma- 
tion of  the  Lachrymal  Gland,  occurs  both  in  an  acute  and  in  a 
chronic  form,  but  is  extremely  rare  in  either.  I  have  seen  one 
case,  of  acute  purulent  dacryoadenitis,  but  no  instance  of  the 
chronic  affection.  Swelling  and  hyper?emia  over  the  gland,  and 
of  the  whole  lid,  with  chemosis  of  the  conjunctiva,  and  much 
local  pain,  increased  on  pressure,  are  the  most  marketl  symptoms 
of  acute  dacryoadenitis.  When  suppuration  has  taken  place,  the 
abscess  may  open  into  the  conjunctiva,  as  it  did  in  my  patient,  or 
through  the  skin.     In  the  latter  case  it  is  liable  to  leave  a  fistula 


THE  LACHRYMAL  APPARATUS.  183 

behind  it,  and  indeed  the  chronic  form  may  also,  it  is  said,  lead 
to  fistula. 

Treatment  in  the  early  stages  consists  in  poultices  and  purga- 
tives. When  pus  has  formed,  the  abscess  may  be  opened  through 
the  skin,  or  from  the  conjunctiva. 

Hypertrophy  of  the  Lachrymal  Gland  is  also  of  rare  occur- 
rence. It  may  attain  such  dimensions  as  to  push  the  eyeball  out 
of  its  position.     It  can  only  be  dealt  with  by — 

Extirpation  of  the  Lachrymal  Gland. — This  operation  has  also 
been  employed  for  cases  in  which  no  other  method  relieved  per- 
sistent epiphora.  It  is  performed  by  making  an  incision  through 
the  integument  under  the  outer  third  of  the  orbital  margin  ;  the 
fascia  under  this  is  dissected  up,  the  gland  drawn  out  with  a 
hook,  and  dissected  out  with  a  scalpel. 


CHAPTER  VIII. 

DISEASES  OF  THE  CORNEA. 

The  importance  of  a  knowledge  of  the  diseases  and  injuries  of 
the  cornea  depends  on  their  great  frequency,  coupled  with  the 
fact  that  nearly  every  one  of  them  is  liable  to  leave  behind  it 
some  opacity,  with  resulting  defect  of  sight  and  disfigurement  of 
the  eye ;  while  several  of  them  are  very  apt  to  lead  to  complete 
loss  of  sight. 

Inflammations  op  the  Cornea. 

From  a  clinical  point  of  view  these  will  be  most  conveniently 
considered  under  the  headings — (a)  Ulcerative  Inflammations 
and  (b)  Non  ulcerative  Inflammations. 

(a)  Ulcerative  Inflammations  of  the  Cornea. — Before 
an  ulcer  can  form  in  the  cornea,  there  must  be  a  cellular  infiltra- 
tion of  its  tissue  near  its  anterior  surface  ;  and  this  cellular  infil- 
tration is  brought  about,  we  nowadays  believe,  by  the  entrance 
into  the  cornea  of  certain  micro-organisms,  the  gonococcus,  or  the 
staphylococcus  pyogenus,  or  other,  as  yet  undescribed,  forms. 
One  recognizes  the  existence  of  an  infiltration  by  seeing  an 
opaque  spot  in  the  cornea,  with  a  dullness  of  the  layers  over  it, 
and  often  of  the  corresponding  part  of  the  epithelium.  Before 
long  the  epithelium  covering  the  infiltration  comes  away,  and 
soon  the  intervening  layers  of  the  true  cornea  break  dowai,  and 
then  we  have  an  ulcer  established. 

But,  although  all  ulcers  of  the  cornea  originate  in  an  infiltra- 
tion ;  yet,  when  once  established,  they  take  on  a  great  variety  of 
type,  in  consequence,  it  may  be,  of  a  variety  in  the  nature  of  the 
originating  micrococcus.  Some  ulcers  are  purulent,  others  non- 
purulent; some  tend  to  spread  over  the  surface  of  the  cornea, 

184 


THE   CORNEA.  185 

others  tend  to  go  deep  into  it ;  some  attack  by  preference  the 
central  region  of  the  cornea,  while  others  are  confined  to  its 
margin ;  some  readily  give  way  to  treatment,  and  others  are 
very  obstinate,  or  almost  incurable.  Again,  some  ulcerative 
corneal  processes  are  attended  by  much  circumcorneal  injection, 
severe  pain  in  and  about  the  eye,  great  reflex  blepharospasm, 
and  lachrymation ;  whilst,  others,  which  may  really  be  more 
severe  processes  in  so  far  as  the  integrity  of  the  eye  is  concerned, 
can  run  their  course  with  scarcely  any  injection  of  the  eyeball, 
and  with  little  or  no  distress  to  the  patient. 

Etiologically,  corneal  ulcers  are  primary  or  secondary.  The 
primary  ulcers  are  those  in  which  the  diseased  process  originates 
in  the  cornea,  most  commonly  as  the  result  of  traumata,  but 
also  in  phlyctenular  keratitis,  or  as  the  result  of  corneal  abscess, 
or  where  the  nutrition  of  the  cornea  is  interfered  wdth,  etc. 
Secondary  ulcers  are  those  which  are  the  result  of  disease  else- 
where, usually  in  the  conjunctiva,  as  in  acute  blennorrhoea,  and 
in  conjunctival  diphtheritis. 

Corneal  ulcers  are  more  common  in  advanced  than  in  early 
life.  Indeed,  in  early  life,  unless  in  cases  of  blennorrhoea  neo- 
natorum and  of  phlyctenular  disease,  corneal  ulcers  are,  I  may 
say,  unknown.  The  greater  liability  to  these  affections  in 
advanced  life  is  due,  no  doubt,  to  a  less  active  nutrition  at  that 
period  in  this  already  lowly  organized  part.  Hence,  slight 
traumata,  or  the  presence  of  a  light  conjunctival  catarrh,  which 
would  have  no  ill  effect  in  a  young  person,  may  form  the  start- 
ing-point of  a  corneal  ulcer  in  an  old  person,  or  even  in  one  of 
middle  age.  For  the  same  reasons  corneal  ulcers  are  much 
more  common  in  the  lower  orders  than  among  the  well-to-do  ;  for 
the  general  nutrition  of  the  poor  is  often  defective,  while  they 
are  more  exposed  to  traumata  than  are  the  better  classes. 

The  Diagnosis  of  the  presence  of  a  large  corneal  ulcer  is  very 
simple.  Inspection  of  the  cornea  in  ordinary  daylight  at  once 
reveals  the  loss  of  substance,  more  or  less  extensive  and  more 
or  less  deep.  If  the  ulcer  be  very  small  and  shallow,  the  diffi- 
culty is  somewhat  greater,  especially  if  there  be  much  blepharo- 
16 


186  DISEASES   OF   THE   EYE. 

spasm.  But,  by  viewing  the  cornea  from  several  different  direc- 
tions, either  by  causing  the  patient  to  move  his  eye,  or  by  the 
surgeon  moving  his  own  head,  and  perhaps  with  the  aid  of  an 
instillation  of  cocaine,  the  depression  in  the  corneal  surface  and 
the  gray  infiltration  of  its  floor  and  margin  will  be  observed. 
It  is  obviously  important  to  decide  at  the  outset  whether  a  gray 
spot  in  the  cornea  be  an  infiltration  (=  a  collection  of  cells 
which  may  shortly  become  an  ulcer),  an  ulcer,  or  a  scar  (=  a 
healed  ulcer  or  other  loss  of  substance).  The  surface  covering 
an  infiltration,  although  flush  with  the  general  surface  of  the 
cornea,  has  usually  a  steamy  appearance,  due  to  some  disorgan- 
ization of  the  cornea,  and  is  not  polished.  With  an  ulcer  the 
appearances  above  indicated  will  be  found.  The  surface  of  a 
scar  is  usually,  although  not  always,  flush  with  the  general  sur- 
face of  the  cornea,  and  it  is  a  polished  surface,  i.  e.,  covered  with 
normal  epithelium,  not  rough,  irregular,  or  even  steamy. 

A  very  beautiful  method  for  ascertaining  the  presence  and 
true  extent  of  a  corneal  ulcer,  or  traumatic  loss  of  substance,  is 
the  instillation  of  a  2  per  cent,  solution  of  fluorescin.  Almost 
immediately  afterwards  the  tissue  forming  the  floor  of  the  loss 
of  substance  assumes  a  greenish  tint,  which  clearly  differentiates 
it  from  the  surrounding  normal  cornea. 

The  presence  of  Hypopyon  {0-6,  under ;  -do'^,  pus)  is  the  rule 
with  some  types  of  corneal  ulcer.  Hypopyon  is  a  deposit  of 
pus  in  the  anterior  chamber,  and,  as  the  patient  sits  or  stands,  it 
lies  in  the  lowest  part  of  the  chamber,  to  which  place  it  has 
gravitated.  If  the  patient  lie  in  bed,  say,  on  the  side  of  the 
affected  eye,  the  hypopyon  will,  of  course,  change  its  position 
and  gravitate  toward  the  outer  side  of  the  chamber.  Some- 
times the  hypopyon  is  so  small  as  to  be  detected  with  difficulty, 
and  again  it  may  fill  the  whole  anterior  chamber,  completely 
obscuring  the  iris.  It  will  be  asked  :  From  whence  does  the 
pus  come  which  forms  hypopyon  in  cases  of  corneal  ulcers  ?  It 
might  be  supposed  that  it  is  derived  directly  from  the  purulent 
floor  of  the  ulcer,  by  passage  of  the  pus-cells  through  the  pos- 
terior layers  of  the  cornea.     But  this  is  not  so.     No  pus-cells 


THE   CORNEA.  187 

do,  or,  indeed,  can,  pass  through  the  membrane  of  Descemet. 
Moreover,  copious  hypopyon  is  often  present  when  the  corneal 
ulcer  is  quite  small  and  non-purulent.  The  pus-cells  which  form 
hypopyon  in  cases  of  corneal  ulcer  come  from  the  iris,  in  com- 
pliance with  the  law  which  causes  leucocytes  to  wander  out  of 
blood-vessels  in  the  neighborhood  of  an  inflammatory  focus,  and 
to  make  their  way  toward  that  focus.  When  these  leucocytes 
from  the  iris  reach  the  anterior  chamber  they  can  go  no  further, 
owing  to  the  barrier  imposed  to  their  progress  by  the  membrane 
of  Descemet. 

The  pus  forming  a  hypopyon  contains,  in  its  early  stages  at 

Fig.  82  (Fuchs). 


least,  no  microbes.  These  interesting  facts  concerning  the  genesis 
and  nature  of  hypopyon  have  been  discovered  by  Professor 
Leber."^ 

The  Dangers  attending  upon  Corneal  Ulcers  are,  first  of  all, 
the  opacities,  the  scars,  which  even  the  slightest  of  them  are  apt 
to  leave  behind. 

Fig.  82  represents  a  section  made  through  a  deep  ulcer  in  its 
progressive  stage.  At  the  margin  of  the  ulcer  the  epithelium 
(e)  and  Bowman's  membrane  (b)  cease.  The  floor  of  the  ulcer 
is  seen  covered  with  pus,  which  also  infiltrates  the  corneal  tissue 
in  the  neighborhood.     As  soon  as  cure   commences,  the  floor  of 

^  Die  Entstehung  der  Entziindung,  Leipzig,  1891. 


188 


DISEASES   OF   THE    EYE. 


the  ulcer  begins  to  get  clear,  i.  e.,  it  becomes  gradually  less 
covered  Avith  pus,  until  it  is  finally  quite  free  from  it,  and  pari 
jxissu  the  surrounding  infiltration  is  absorbed.  Then,  the  epithe- 
lium, growing  in  from  the  margin  (m  m,  Fig.  83)  all  round, 
gradually  carpets  over  the  floor  of  the  ulcer,  and,  underneath 
this  newly  formed  epithelium,  the  new  tissue,  which  is  to  close 
the  loss  of  substance,  is  laid  down.  This  new  tissue,  however,  is 
not  corneal  tissue,  but  is  ordinary  connective  tissue,  and  is  there- 
fore opaque.  Hence,  the  deeper  the  ulcer  has  been,  the  more 
intense  will  be  the  resulting  opacity.  Bowman's  membrane 
never  becomes  restored  over  the  cicatrix. 

Fig.  83  (Fuchs). 
m  m 


^ 


The  ulcers  which  are  situated  at  the  centre  of  the  cornea,  in 
the  pupillary  area,  are  more  serious  for  sight,  than  those  situated 
peripherally,  as  can  be  readily  understood.  The  opacity  left  by 
a  very  superficial  ulcer  is  slight,  and  is  called  a  nebula ;  a  some- 
what more  intense  opacity  is  called  a  macula ;  and  a  very 
marked  white  scar  is  called  a  leucoma. 

But  a  more  serious  danger  connected  wath  ulcers  of  the  cornea 
than  the  opacities  they  leave  behind  is  that  of  perforation  of  the 
cornea,  to  which  some  ulcers  are  very  prone.  For  an  account  of 
the  consequences  of  perforation  see  pp.  107,  193,  and  212  (on 
Staphyloma  Cornese.) 

In  the  Treatment  of  primary  corneal  ulcers  the  student  will 


THE   CORNEA.  189 

soon  perceive  that  a  bandage,  atropine,  and  warm  fomentations 
play  prominent  parts. 

The  bandage  should  be  put  on  with  firm  pressure,  but  should 
not  be  made  uncomfortably  tight,  the  eye  having  been  pre- 
viously padded  out,  especially  at  the  inner  canthus,  so  that 
equal  pressure  may  be  exercised  on  the  globe  all  over.  The 
support  thus  given  to  the  cornea  and  front  of  the  eye  promotes 
the  healing  process  in  the  ulcer,  and  the  bandage  is  also  useful 
by  preventing  the  eyelids  from  rubbing  over  the  ulcer,  and  by 
keeping  small  foreign  bodies  from  it.  In  secondary  ulcers,  due 
to  severe  conjunctival  processes,  such  as  blenuorrhoea,  a  bandage 
is  contraindicated,  because  it  retains  the  secretion,  and  therefore 
would  do  more  harm  than  good. 

Atropine,  in  sufficient  quantities  to  keep  the  pupil  dilated, 
should  be  employed.  Iritis  very  often  attends  severe  corneal 
ulcers,  and  here  the  indication  for  atropine  is  apparent.  But 
rest  of  the  affected  part  is,  we  know,  an  important  element  in 
preventing  or  in  curing  any  inflammation,  and  in  the  affections 
we  are  now  treating  of,  even  where  there  is  no  iritis,  atropine 
acts  by  procuring  rest  of  the  iris  and  of  the  ciliary  muscle,  the 
constant  motion  of  which  would  otherwise  tend  to  augment  the 
inflammatory  process  in  the  cornea. 

Some  surgeons  use  myotics  (eserine  or  pilocarpine)  in  prefer- 
ence to  atropine  in  the  treatment  of  corneal  ulcers.  They  hold 
that  their  power  of  reducing  the  intraocular  tension  encourages 
healing  of  the  ulcers,  while  they  also  think  the  more  extended 
surface  of  iris  presented  facilitates  absorption  of  the  hypopyon. 
But  it  is  doubtful  whether  myotics  do  reduce  the  normal  ten- 
sion, although  they  often  have  that  eflect  upon  abnormal  tension, 
and  my  objection  to  them  in  these  cases  is  that  they  increase,  I 
believe,  the  tendency  to  iritis.  Absorption  of  the  hypopyon  will 
only  come  about  when  the  cornea  begins  to  recover,  whatever 
the  treatment  may  be.  I  am  not  singular  in  this  view  of  the 
use  of  eserine  in  corneal  ulcers.  An  indication  for  myotics, 
however,  is  given  by  the  presence  of  an  ulcer  near  the  corneal 
margin  with  a  tendency  to  perforate,  for  here  the  myosis  would 


190 


DISEASES   OF   THE    EYE. 


Fig.  84.       assist  in   preventing  prolapse  of  the  iris,  should 
perforation  take  place. 

Warm  fomentations  promote  the  healing  pro- 
cess by  stimulating  tissue-changes  in  the  cornea. 
One  usually  orders  them  to  be  made  with  poppy- 
head  water  or  chamomile  tea,  although  no  doubt 
warm  water   would   be  equally  efficacious.     The 

I  bandage  having  been  removed  a  compress  of  lint 
/'^  dipped  in  the  stupe  at  about  120°  Fahrenheit  is 
laid  upon  the  eye  and  frequently  replaced  by 
fresh  compresses  out  of  the  stupe,  so  that  the  one 
on  the  eye  may  be  always  hot.  This  is  continued 
for   half  an  hour  at  a  time  and  repeated  every 

'.    two  or  three  hours. 

^  In  an  ulcer  of  a  purulent  or  sloughing  nature 
the  insufflation  on  its  floor  of  very  finely  divided 
iodoform  powder  is  useful. 

g  Thorough  scraping  of  the  floor  of  the  ulcer 
with  a  small  sharp  spoon  is  a  very  important  and 
valuable  method. 

The  actual  cautery  has  of  late  years  come  much 
into  use  in  the  treatment  of  purulent  and  serpigi- 
nous corneal  ulcers.  It  acts  by  destroying  the 
micro-organisms  which  keep  the  process  going. 
Either  a  thermo-cautere,  in  the  form  of  a  very 
fine  point,  or  the  galvano-cautery  (Fig.  84)  may 
be  employed.  To  the  latter  a  medium-sized 
bichromate  of  potash  bottle-battery  is  attached 
and  the  platinum  wire  brought  to  a  red  heat. 
The  eye  having  been  cocainized  the  red-hot 
cautery  is  brought  into  contact  with    the  whole 


Fig.  84.  The  bolt  a  being  pushed  forward,  the  current 
is  completed  and  passes  through  the  platinum  wire 
which  forms  the  cautery.  By  pressure  on  the  button  b 
the  current  can  be  momentarily  intercepted  during  use 
of  the  instrument. 


THE    CORNEA.  191 

surface  of  the  ulcer  so  as  to  thoroughly  destroy  its  superficial 
layer,  and  special  attention  is  paid  to  any  part  of  the  margin 
of  the  ulcer  where  it  seems  inclined  to  spread  to  as  yet  healthy 
tissue.  The  cauterization  may  be  repeated  as  often  as  the 
progress  of  the  ulcer  makes  it  desirable.  It  is  well  to 
perforate  the  cornea  with  the  cautery  and  to  evacuate 
the  aqueous  humor  and  hypopyon,  or  this  may  be  done 
with  an  ordinary  paracentesis  needle  after  the  cauteriza- 
tion is  completed.  My  own  experience  of  the  cautery 
in  these  cases  is  extremely  satisfactory.  It  seems  to 
give  the  best  percentage  of  cures  with  the  least  amount 
of  opacity. 

Paracentesis  of  the  anterior  chamber  through  the 
floor  of  the  ulcer  is  another  most  valuable  therapeutic 
measure  for  some  corneal  ulcers  and  deserves  a  more 
routine  application  in  these  cases  than  is  accorded  to  it, 
the  more  so  as  the  valuable  little  operation  is  simple  and 
dangerless.  But  there  are,  I  think,  two  imperative  indi- 
cations, two  golden  rules  for  its  use,  namely :  (1)  If. 
there  be  great  pain.  Very  shortly  after  the  operation, 
which  for  the  moment  increases  the  neuralgia,  the 
patient  experiences  the  greatest  relief  and  passes  the 
first  good  night  after  many  wakeful  ones.  (2)  If  per- 
foration seem  to  be  imminent.  This  may  often  be  recog- 
nized by  a  bulging  forward  of  the  thin  floor  of  the  ulcer, 
but  sometimes  it  is  not  easily  foreseen,  and  if  there  be 
any  doubt  on  the  point  paracentesis  should  be  performed. 
It  is  important  to  forestall  spontaneous  perforation  of 
the  ulcer  by  this  proceeding,  because  the  opening  made 
by  the  latter  being  linear,  it  heals  easily  and  leaves  but 
a  slight  scar  without  anterior  synechia,  while  the  natu- 
ral opening  would  be  a  complete  loss  of  substance,  and  there- 
fore the  more  readily  involve  adhesion  of  the  iris  in  the  result- 
ing comparatively  extensive  cicatrix. 

Paracentesis  of  the   anterior  chamber  is  best  performed  by 
means  of  a  paracentesis  needle  (Fig.  85},  which  is  a  somewhat 


192  DISEASES   OF   THE   EYE. 

shovel-shaped  instrument  with  a  shoukler  or  stop.  If  this  be 
not  at  hand  a  small  iridectomy  knife  or  a  broad  needle  will 
answer  the  purpose.  The  eye  having  been  cocainized,  a  spring 
lid -speculum  is  inserted,  the  eye  fixed  with  a  fixation  forceps, 
and  the  point  of  the  paracentesis  needle  applied  to  the  floor 
of  the  ulcer  in  such  a  way  that  the  plane  of  the  little  blade  may 
be  at  an  angle  of  about  45°  with  that  of  the  floor  of  the  ulcer. 
The  point  is  pushed  gently  through  the  floor,  and  the  plane 
of  the  blade  is  then  immediately  changed,  so  that  as  the  instru- 
ment is  being  advanced  up  to  the  shoulder,  it  may  be  almost  in 
contact  with  the  posterior  surface  of  the  cornea.  The  with- 
drawal of  the  instrument  should  be  effected  with  extreme  slow- 
ness, in  order  that  the  aqueous  humor  may  flow  off  gradually 
and  not  with  a  rush.  If  these  precautions  be  taken  there  need 
be  no  danger  of  injuring  the  crystalline  lens,  of  causing  intra- 
ocular hemorrhage,  or  of  having  prolapse  of  the  iris  in  the 
incision.  If  the  latter  should  occur  it  can  usually  be  reposed 
with  the  spatula.  It  may  happen  that  when  the  needle  has  been 
quite  withdrawn,  a  considerable  portion  of  the  aqueous  humor 
may  still  remain  in  the  anterior  chamber,  unable  to  escape  owing 
to  the  valve-like  closure  of  the  wound.  It  should  be  evacuated 
by  making  the  wound  gape  by  gentle  pressure  with  a  spatula  on 
its  posterior  lip.  If  it  be  desirable  to  tap  the  anterior  chamber 
on  the  next  day  it  can  be  done  by  simply  opening  up  the  wound 
with  a  spatula  or  with  the  probe-like  instrument  at  the  other  end 
of  the  handle  (Fig.  85),  without  the  aid  of  any  cutting  instru- 
ment. 

If  the  case  do  not  come  under  the  care  of  the  surgeon  until 
perforation  of  the  ulcer  with  prolapse  of  the  iris  has  taken  place, 
the  very  important  question  as  to  the  best  method  of  dealing 
with  the  condition  is  presented.  The  same  question  arises  in 
other  forms  of  perforating  ulcer.  If  the  loss  of  substance 
occupy  one-third  or  more  of  the  cornea,  with  correspondingly 
large  prolapse  of  iris,  little  can  be  done  beyond  the  use  of 
eserine — and  here  I  would  use  eserine — to  reduce  the  intraocular 
pressure,  along  with  the  application  of  a  firm  bandage  ;  for  in 


THE    CORNEA.  193 

such  cases  the  formation  of  a  corneal  staphylonaa  is  almost  inev- 
itable. But  if  the  ulcer  and  prolapse  be  small,  an  attempt  may 
be  made  to  free  the  iris  ;  so  that  no  anterior  synechia  may  form, 
or,  that  the  cicatrix  may  be  flat,  and  not  raised  over  the  surface  of 
the  cornea,  and,  therefore,  exposed  to  injury.  The  importance 
of  such  an  attempt  lies  in  the  fact  that  a  corneal  cicatrix  with 
iris  entangled  in  it — not  merely  adherent  to  its  posterior  surface — 
affords  a  constant  source  of  danger,  especially  if  situated  near 
the  margin  of  the  cornea ;  for,  in  such  eyes,  sudden  and  uncon- 
trollable purulent  inflammation  of  the  iris  and  choroid  may 
come  on,  after  an  apparently  slight  trauma,  and  end  in  total 
destruction  of  the  eye.  This  event  is  due  to  septic  infection 
reaching  the  interior  of  the  eye  through  a  superficial  loss  of  sub- 
stance, the  direct  result  of  the  trauma.  The  surgeon's  attention 
should,  therefore,  be  directed  to  obtain  at  least  as  flat  a  cicatrix 
as  possible,  or,  still  better,  a  non-adherent  cicatrix.  The  prac- 
tice which  I,  as  well  as  many  other  surgeons,  have  commonly 
followed,  is  to  draw  the  prolapsed  portion  of  iris  slightly  for- 
ward with  a  forceps,  and  to  snip  it  off  level  with  the  surface  of 
the  cornea ;  and  then,  with  a  spatula,  to  endeavor  to  free  the  iris 
from  any  adhesions  it  may  have  formed  with  the  margin  of  the 
ulcer.  Atropine  or  eserine,  according  to  the  position  of  the 
ulcer,  is  then  instilled,  and  a  bandage  carefully  applied.  This 
proceeding  is  only  of  use  when  a  fresh  prolapse  can  be  dealt 
with,  before  cicatrization  sets  in  ;  and  the  result  is  often  satisfac- 
tory, so  far  as  the  securing  of  a  flat  cicatrix  is  concerned,  but 
an  anterior  synechia  can  rarely  be  avoided. 

Dr.  da  Gama  Pinto  has  successfully  employed  the  following 
method  for  obtaining  a  non-adherent  cicatrix  :  Having  abscised 
the  prolapsed  portion  of  iris  as  above,  and  freed  all  adhesions  to 
the  margin  of  the  ulcer  with  a  spatula,  he  covers  the  opening  in 
the  cornea  with  a  flap  cut  from  the  bulbar  conjunctiva,— and 
this  flap  should  be  twice  as  large  as  the  opening,  in  order  to 
admit  of  its  shrinkage, — and  then  pushes  the  flap  into  the 
opening  with  a  blunt  probe.  A  firm  binocular  bandage  is 
applied— but  no  iodoform.  The  eye  is  not  dressed  until  the 
17 


194  DISEASES   OF   THE   EYE. 

third  day,  when  the  anterior  chamber  is  often  found  restored, 
the  iris  all  in  its  proper  plane,  and  the  conjunctival  flap  healed 
into  the  ulcer.  Ultimately,  all  trace  of  the  flap  disappears, 
and  an  ordinary  non-adherent  corneal  scar  is  presented.  I  have 
employed  this  method  twice,  and  in  each  case  with  a  good 
result. 

From  time  to  time  diflferent  types  of  corneal  ulcers  have 
been  recognized  and  described,  and  the  following  are  the  chief 
of  them  : — 

Simple  Ulcer. — This  may  result  from  a  slight  trauma,  or  from 
the  bursting  of  a  phlyctenula.  It  presents  the  appearance  of  a 
minute  and  shallow  depression,  with  a  gray  floor,  on  the  surface 
of  the  cornea.  There  is  cicumcorneal  vascularity,  especially  at 
that  part  of  the  corneal  margin  nearest  to  which  the  ulcer  is 
situated  ;  the  pupil  is  apt  to  be  contracted,  although  iritis  is 
not  present ;  and  there  is  often  a  good  deal  of  pain,  lachrymation, 
and  photophobia. 

Treatment  and  Prognosis. — The  eye  is  to  be  bandaged,  warm 
fomentations  applied  several  times  a  day,  and  a  drop  of  solution 
of  atropine  instilled  night  and  morning.  When  of  phlyctenu- 
lar origin,  stimulation  with  the  yellow  oxide  ointment  is 
indicated.  Cure,  with  slight  opacity  remaining,  comes  about  in 
a  week  or  ten  days.  But,  occasionally,  this  form  of  ulcer  may 
pass  over  to  the  deep  ulcer. 

Deep  TJlcer. — This  is  a  purulent  ulcer,  and  commences  in 
a  purulent  infiltration  of  the  cornea.  It  forms  a  tolerably 
deep  pit  in  the  cornea,  toward  its  centre,  the  floor  of  the 
ulcer  being  covered  with  purulent  deposit  and  detritus,  and 
the  corneal  tissue  immediately  surrounding  it  being  some- 
what infiltrated  with  pus.  The  ulcer  is  generally  round,  but 
it  may  assume  any  shape.  Hypopyon  is  often  present,  and 
a  marked  tendency  to  iritis  exists.  The  pain  is  usually  very 
severe,  violent  frontal  neuralgia  being  a  common  symptom. 

This  ulcer  has  no  great  tendency  to  spread  over  the  surface 
of  the  cornea,  but  has  a  very  decided  tendency  to  perforate 
through  it.     As   it  does  not  generally  attain  wide  dimensions. 


THE   CORNEA.  195 

the   perforation   it  may  produce  is  small,  and  gives  rise  to  a 
small  adherent  leucoma,  rather  than  to  a  staphyloma. 

Causes. — This  form  of  ulcer  is  a  frequent  one  in  purulent 
conjunctivitis,  and  it  may  be  caused  by  the  lodgment  of  foreign 
bodies,  and  other  injuries  of  the  cornea. 

Treatment. — If  the  ulcer  be  due  to  a  conjunctival  process, 
the  latter  should  be  actively  treated. 

If  the  cause  be  other  than  conjunctival,  a  pressure  bandage, 
to  give  support  to  the  ulcer,  is  important,  and  periodical  warm 
fomentations  are  most  beneficial.  Atropine  should  be  instilled 
several  times  daily.  Antiseptic  applications  too,  especially 
iodoform  in  finely  divided  powder,  are  useful. 

Paracentesis  of  the  anterior  chamber  through  the  floor  of  the 
ulcer  is  a  proceeding  always  followed  by  improvement  in  the  con- 
dition of  the  eye,  and  is  very  important  as  a  preventive  of 
natural  perforation.  The  actual  cautery,  too,  is  in  its  place 
here. 

TJlcus  Serpens  (Ssemisch's  Ulcer,  Infecting  Ulcer).  This, 
also,  is  a  purulent  ulcer,  the  characteristic  of  which  is  its  ten- 
dency to  extend  over  the  surface  of  the  cornea,  especially  in 
some  one  direction,  rather  than  to  strike  deep  into  its  tissue. 
Its  position  is  chiefly  central,  and  it  presents  a  grayish  floor, 
which  is  more  intensely  opaque  at  some  places.  One  part  of  the 
margin  takes  the  form  of  a  curve,  or  of  several  closely  placed 
curves,  and  at  this  place  becomes  yellowish- white  in  color  and 
somewhat  raised,  and  the  floor  of  the  ulcer  seems  deeper  in  its 
neighborhood.  Immediately  around  the  ulcer  the  cornea  is 
slightly  opaque,  but  further  out  it  is  quite  normal. 

The  degree  of  pain  and  irritation  varies  much,  being  almost 
absent  in  some  cases,  while  in  others,  it  is  extremely  intense. 
Iritis  is  apt  to  come  on  at  an  early  period,  and  may  pass  into 
irido-cyclitis.  Hypopyon  is  almost  always  present.  The  ulcer 
creeps  over  the  surface  of  the  cornea  in  the  direction  of  the 
curved  and  intensely  infiltrated  margin.  At  a  still  later  stage 
the  whole  cornea  is  apt  to  become  infiltrated,  and  the  entire 
margin  of  the  ulcer  to  extend,  and  the  anterior  chamber  becomes 


196  DISEASES   OF   THE   EYE. 

quite  full  of  pus.  Perforation  now  takes  place,  or  may  do  so 
somewhat  earlier.  If  the  perforation  be  small,  an  adherent 
leucoma  results ;  but,  if  large,  a  staphyloma  is  produced. 

Causes. — Ulcus  Serpens  always  has  its  origin  in  a  superficial 
corneal  abscess  (vide  p.  205),  caused  in  its  turn  by  a  trauma, 
which  has  produced,  it  may  be,  only  a  slight  abrasion  of  the 
epithelium.  In  a  large  percentage  of  the  cases  chronic 
dacryocystitis  is  present,  and  a  considerable  proportion  of  them 
occur  in  the  agricultural  population,  especially  in  harvest-time. 
The  investigations  of  Leber,*  and  others,  make  it  probable 
that  a  fungus  (aspergillus)  obtaining  entrance  through  the  loss 
of  epithelium  sets  up  the  abscess,  which  results  in  this  peculiar 
ulcerative  process.  This  fungus  is  probably  present  in  the  ab- 
normal secretion  of  the  lachrymal  sac,  or  floats  in  the  air  during 
the  oats,  barley,  and  wheat  harvest. 

Prognosis. — From  the  above  description  it  will  be  seen,  that 
the  process  is  a  very  severe  one  in  many  instances,  and  the 
prognosis  bad  ;  yet,  some  cases  do  recover  useful,  although 
damaged,  sight,  under  careful  treatment,  if  it  has  been  resorted 
to  in  time. 

Treatment. — If  the  case  be  not  severe,  atropine,  with  protection 
of  the  eye,  may  cure  in  a  few  days.  Here,  too,  some  surgeons 
prescribe  eserine,  and  I  am  opposed  to  its  use  (p.  104).  Warm 
fomentations  are  useful ;  and  a  pressure  bandage,  provided  there 
be  no  dacryocystitis.  Antiseptic  measures  should  always  be  em- 
ployed, iodoform  being  the  application  most  likely  to  prove  of 
use.  It  may  be  employed  either  in  the  form  of  a  strong  oint- 
ment (gr.  XXV  ad  5j)  put  into  the  eye,  or  it  may  be  dusted  on 
the  floor  of  the  ulcer  with  a  camel's-hair  pencil.  Scraping  the 
floor  of  the  ulcer  with  a  sharp  spoon  has  also  been  suggested. 
But  it  is  in  all  respects  wiser  to  deal  with  these  cases,  even  the 
apparently  mild  ones,  actively  in  the  very  commencement,  by 
means  of  one  or  other,  preferably  the  second,  of  the  two  follow- 
ing methods. 

*  V.  Graefe's  Archiv,  xxv,  pt.  2,  p.  285. 


THE   CORNEA.  197 

Ssemisch's  Method  consists  in  division  of  the  ulcer  with  a 
Graefe's  cataract  knife.  Cocaine  having  been  applied,  the  point 
of  the  instrument  is  entered  about  2  mm.  from  the  margin  of 
the  ulcer  in  the  healthy  corneal  tissue,  and,  having  been  passed 
through  the  anterior  chamber  behind  the  ulcer,  the  counter- 
puncture  is  made  in  the  healthy  cornea  some  2  mm.  from  the 
opposite  margin  of  the  ulcer.  The  edge  of  the  knife  being  then 
turned  forward,  the  section  is  slowly  completed.  The  incision 
should  divide  the  intensely  infiltrated  part  of  the  margin  in 
halves.  The  aqueous  humor  and  hypopyon  are  evacuated, 
atropine  is  instilled,  a  bandage  is  applied,  and  the  patient  soon 
gets  relief  from  pain.  Every  day,  until  healing  of  the  ulcer  is 
well  established,  the  wound  must  be  opened  up  from  end  to  end 
with  the  point  of  a  fine  probe  or  spatula,  the  contents  of  the 
anterior  chamber  being  thoroughly  evacuated  on  each  occasion, 
and  atropine  instilled.  The  result  is  that,  in  a  vast  majority  of 
cases,  the  progress  of  the  ulcer  is  arrested,  and  healing  soon  sets 
in.  The  little  operation  should  not  be  delayed  long,  but  it  may 
be  employed  with  advantage  even  in  late  stages  of  the  process. 

But  the  actual  cautery  is  the  most  valuable  method  of  treat- 
ment for  this  ulcer.  The  infiltrated  and  undermined  margin  of 
the  ulcer  is  the  part  which  should  be  most  thoroughly  cauterized  ; 
but  its  floor,  if  much  infiltrated,  is  also  to  be  dealt  with.  The 
application  of  fluorescin  just  before  the  use  of  the  cautery  is  of 
much  value,  as  it  enables  the  operator  to  clearly  discern  the 
whole  of  the  diseased  part  requiring  cauterization. 

Rodent  Ulcer. — This  is  a  rare  and  extremely  dangerous  form 
of  ulcer.  It  appears  as  a  small — sometimes  even  pin-head — gray 
infiltration  near  the  corneal  margin,  not  differing  in  appearance 
from  many  a  harmless  infiltration.  This  rapidly  ulcerates. 
Other  similar  infiltrations  appear  in  the  neighborhood  and  at 
other  parts  of  the  margin,  and  ulcerate.  The  ulcers  do  not  go 
deeper  than  about  one-third  of  the  thickness  of  the  cornea. 
They  never  penetrate.  Before  long  they  begin  to  heal,  but  leave 
an  intense  cicatrix  behind.  After  a  time  more  such  ulcers  form 
inside  the  position  occupied  by  the  first  irruption,  and  these  also 


198  DISEASES   OF   THE   EYE. 

heal,  leaving  further  opacity.  This  process  goes  on  until,  finally, 
the  whole  surface  of  the  cornea  has  been  eaten  away,  its  centre 
being  the  last  place  affected,  and  then  loss  of  sight  is  complete. 
The  disease  usually  comes  on  in  both  eyes,  although  there  may 
be  an  interval  between  the  onset  in  each.  It  attacks  decrepit 
people  over  middle  life.  The  progress  of  the  disease  is  very 
slow,  as  many  weeks,  or  even  some  months,  may  elapse  before 
the  surface  of  the  whole  cornea  has  been  destroyed. 

Treatment. — Some  of  these  cases  are  amenable  to  the  actual 
cautery,  and  then  its  use  will  arrest  the  disease  and  save  the  eye. 
But  I  have  seen  cases  in  which  this  and  every  other  conceivable 
treatment  was  tried  in  vain,  and  where  both  eyes  were  irretriev- 
ably lost. 

Marginal  Ring  TJlcer  is  a  rare  form,  which  commences  as  a 
clean-cut,  or  but  slightly  infiltrated,  yet  rather  deep,  ulcer  at 
the  corneal  margin.  Its  tendency  is  to  extend  along  the  margin 
of  the  cornea;  and,  in  some  instances,  healing  takes  place  in  the 
older  parts  of  the  ulcer,  while  it  is  still  progressive  at  the  newer 
parts.  It  may  extend  all  round  the  cornea,  and  finally  give 
rise  to  complete  sloughing  of  the  latter  by  cutting  off"  its  nutri- 
tion. This  ulcer  may  result  in  children  from  a  marginal 
phlyctenular  infiltration  (p.  125),  but  is  more  common  in  adults, 
or  in  aged  people,  whose  nutrition  has  fallen  very  low. 

Treatment. — The  actual  cautery.  Paracentesis  through  the 
ulcer,  eserine  having  been  first  instilled.  Insufflation  of  iodo- 
form. Warm  fomentations.  A  bandage.  Quinine,  iron,  and 
strychnine  internally,  with  nutritious  diet. 

Absorption  TJlcer  (Faceted  Ulcer,  Superficial  Transparent 
Ulcer)  is  the  term  applied  to  a  certain  definite  superficial  ulcera- 
tion, which  is  accompanied  by  but  little  opacity,  and  by  no 
vascularization,  and  which  is  usually  seated  at  or  near  the 
centre  of  the  cornea,  where  it  presents  the  appearance  of  a 
shallow  pit  about  2  mm.  broad,  with  rounded  margin.  If  the 
eye  be  exposed  to  cold  wind,  or  other  irritation,  some  circum- 
corneal  injection  makes  its  appearance,  and  the  eye  waters,  but 
these  symptoms  soon  pass  off  again.     The  portions  destroyed  by 


THE    CORNEA.  199 

the  ulcerative  process  come  away  in  the  course  of  a  few  weeks, 
the  surface  begins  to  be  covered  with  new  epithelium,  and 
reparation  of  the  corneal  tissue  commences.  It  takes  months  for 
this  healing  process  to  be  completed  ;  and,  often,  the  defect  is 
never  quite  filled  up,  but  a  small  facet  is  left,  which  is  liable  to 
interfere  with  vision. 

The  absorption  ulcer  does  not  tend  to  perforate,  nor  to  spread 
over  the  surface  of  the  cornea. 

It  occurs  chiefly  in  childhood,  and  probably  indicates  mal- 
nutrition of  the  general  system  ;  some  observers,  indeed,  think 
there  is  a  close  relationship  between  it  and  phlyctenular  ophthal- 
mia. It  is  also  seen  in  granular  ophthalmia,  with  and  without 
panuus. 

Treatment  consists  in  atropine  and  protection  in  the  early 
stages,  and  the  yellow  precipitate  ointment  when  the  epithelium 
has  become  restored. 

Neuro-Paralytic  Keratitis. — In  paralysis  of  the  Ophthalmic 
Division  of  the  Fifth  Nerve,  purulent  infiltration  and  ulceration 
of  the  cornea  is  often  observed.  It  was  formerly  believed  that 
the  fifth  nerve  had  an  influence  over  the  nutrition  of  the  cor- 
nea, and,  hence,  that  this  was  a  trophic  process;  but  experiment 
has  shown  that  this  is  not  the  case,  and  that  the  affection  is 
merely  due  to  the  loss  of  sensation,  which  renders  it  possible  for 
foreign  substances  to  remain  on  the  cornea,  unremoved  by  a 
reflex  motion  of  the  lid.  This  disease,  therefore,  cannot  be  re- 
garded as  of  neuropathic  origin,  in  the  strict  sense  of  the  term. 

Treatment  consists,  chiefly,  in  protection  of  the  cornea  by  a 
bandage  on  the  eye ;  or,  by  keeping  the  lids  fastened  together 
with  a  dermic  suture. 

Infantile  Ulceration  of  the  Cornea,  with  Xerosis  of  the 
Conjunctiva,  first  described  by  von  Graefe,"^  is  a  very  rare  aflfec- 
tion,  of  which  a  few  cases  came  under  my  care  at  von  Graefe's 
clinique.  It  attacks  some  wretchedly  delicate,  marasmatic  chil- 
dren early  in  the  first  year  of  life,  making  its  appearance  at,  or 

*A.  V.  Graefe^s  Archiv.,  xii,  pt.  2,  p.  250. 


200  DISEASES    OF   THE    EYE. 

near  the  centre  of  the  cornea.  Iritis  always  supervenes  n  severe 
cases.  That  portion  of  the  bulbar  conjunctiva  which  is  exposed 
in  the  palpebral  aperture  at  either  side  of  the  cornea,  undergoes 
slight  epithelial  xerosis.  Ulceration  of  the  cornea  soon  comes 
on,  through  necrosis  of  the  layers  lying  over  an  interstital  infil- 
tration ;  and  this  ulceration  spreads,  until  it  involves  the  whole 
of  the  cornea,  except  a  very  narrow  margin.  Finally,  perfora- 
tion, with  prolapse  of  the  iris,  and  panophthalmitis,  may  super- 
vene. 

Both  eyes  beconie  affected,  as  a  rule,  although  the  disease 
usually  attacks  one  some  time  before  its  fellow.  The  patients 
almost  always  die  of  diarrhoea,  pneumonia,  etc. 

Cause. — Streptococci  have  been  found*  in  the  corneal  ulcer, 
and  in  the  conjunctiva  ;  while  a  general  invasion  of  the  vascu- 
lar system  of  the  whole  body  is  also  present.  To  the  latter 
circumstance  are  referred  the  symptoms,  which  lead  to  a  fatal 
termination. 

Treatment  is,  unfortunately,  of  very  little  avail ;  but  warm 
fomentations,  and  the  use  of  non-irritating  and  aseptic  lotions, 
etc.,  are  indicated,  along  with  an  antiseptic  bandage.  Such 
means  as  may  promote  improvement  of  the  general  system  will, 
of  course,  be  employed. 

Herpes  Corneae. — Not  only  in  herpes  zoster  ophthalmicus,  but 
also  in  herpes  febrilis  (or  catarrhalis)  is  a  vesicular  eruption 
liable  to  occur  on  the  cornea.  According  to  Horner,  herpes 
corne?e  febrilis  is  a  rather  common  affection,  and,  he  believed, 
is  often  not  recognized  by  ophthalmologists,  because  it  usually 
first  comes  under  their  notice  when  the  secondary  ulcers  have 
formed.  The  following  is  Professor  Horner's  description  of  the 
disease : — 

On  the  surface  of  the  cornea  of  one  eye  is  formed  a  group  of 
clear  vesicles,  each  from  0.5  to  1.0  mm.  in  diameter,  their 
appearance  being  accompanied  by  much  lachrymation,  but  with- 
out any  swelling  of  the  eyelid.      They  usually  form  in  a  line, 

*  Leber  and  Wagenmann,  A.  v.  Graefe^s  Archiv,  xxxiv,  4,  p.  250. 


THE   CORNEA.  201 

which  runs  obliquely  across  the  cornea,  or  sometimes  in  a  verti- 
cal direction.  Now  and  then  they  are  arranged  in  trefoil  shape, 
or  in  a  circle.  The  covering  of  the  vesicles  is  short-lived,  and, 
as  already  remarked,  the  resulting  ulcer  is  that  which  the  sur- 
geon usually  first  sees.  Even  it,  however,  is  thoroughly  charac- 
teristic. On  the  surface  of  the  clear  cornea  is  an  irregular  loss 
of  epithelium,  along  the  margins  of  which  may  still  sometimes 
be  seen  the  shreds  of  the  late  covering  of  the  vesicle.  The  mar- 
gin of  the  region  which  is  bared  of  its  epithelium  is  dentated, 
and  can  only  be  mistaken  for  a  traumatic  loss  of  epithelium. 
The  latter,  however,  would  never  present  the  peculiar  "string- 
of- beads"  appearance.  The  floor  of  the  loss  of  substance  is 
formed  by  the  superficial  layers  of  the  cornea,  and  the  anaesthesia 
of  the  cornea  is  confined  to  this  place — and  does  not,  as  in 
herpes  zoster,  extend  to  the  rest  of  the  cornea.  The  tension  of 
the  eye  is  generally  reduced.  Under  favorable  circumstances 
this  loss  of  epithelium  may  be  rapidly  repaired;  although,  even 
then,  more  slowly  than  one  of  equal  dimensions  but  of  trau- 
matic origin.  Usually  the  healing  process  is  slow,  and  some- 
times more  or  less  intense  opacities  form  in  the  area  and  at  the 
margin  of  the  ulcer,  with  hypopyon,  iritis,  etc.,  and  the  loss  of 
substance  becomes  deep,  with  a  dentated  margin.  This  more 
unfavorable  course  is  the  result  of  secondary  infection  of  the 
ulcer. 

The  subjective  sensations  are  those  of  a  foreign  body  in  the 
eye,  with  lachrymation  and  photophobia,  and  are  relieved  imme- 
diately after  the  bursting  of  the  vesicles. 

The  vesicular  eruption  is  often  regarded  as  irritation  from  a 
foreign  body  merely  ;  or,  occurring  in  the  course  of  a  serious 
disease  (pneumonia,  typhoid  fever,  intermittent  fever,  etc.),  it 
passes  wholly  unnoticed,  and  its  relationship  to  the  latter 
remains  unrecognized. 

The  only  aflTection  for  which  herpes  cornese  is  likely  to  be 
mistaken  is  phlyctenular  keratitis;  but  the  clear,  elevated 
vesicles  will  readily  be  distinguished  from  the  flatter  grayish 
mass  of  cells,  which  form   the  phlyctene.     In  herpes  there  is 


202  DISEASES   OF   THE   EYE. 

never — although  often  in  phlyctenular  keratitis — a  vasculariza- 
tion of  the  cornea.  The  shape  of  the  loss  of  epithelium  after 
bursting  of  a  herpes  vesicle  is  characteristic.  Phlyctenular 
keratitis  is  a  disease  of  childhood,  while  herpes  corneoc  is  rare 
under  puberty. 

The  derangements  of  the  system  in  which  herpes  corneal  febrilis 
occurs  are  naturally  those  in  which  herpes  febrilis  labii,  nasi, 
etc.,  are  found.  These  are,  more  especially,  the  inflammatory 
affections  of  the  respiratory  tract,  from  an  acute  catarrh  of  the 
Schneiderian  mucous  membrane  to  a  severe  pneumonia.  On 
two  occasions,  with  an  interval  of  three  years,  Professor  Horner 
saw  herpes  corne?e  occur  in  the  course  of  an  attack  of  pneumonia 
in  a  boy.  In  just  such  cases,  herpes  on  the  lips,  ala  nasi,  exter- 
nal ear,  and  eyelid  of  the  same  side  are  found  ;  and,  in  a  case  of 
double  pneumonia  in  an  adult,  occurred  the  only  binocular 
herpes  corne?e  which  Professor  Horner  had  seen.  He  explicitly 
states  that  he  had  seen  herpes  corneie  in  connection  with 
whooping  cough,  and  often  with  intermittent  and  typhoid 
fevers. 

But  primary  herpes  cornese — i.  e.,  unconnected  with  any  other 
disease — is  occasionally  met  with,  and  some  patients  are  liable 
to  recurrent  attacks  of  it.  It  is  accompanied  by  severe  neuralgia 
in  the  frontal  and  temporal  regions,  and  pain  on  pressure  of  the 
supraorbital  notch  may  be  present.  There  is  much  lachrymation. 
The  upper  lid  is  red  and  swollen.  The  bulbar  conjunctiva, 
especially  around  the  cornea,  is  much  infected,  and  there  may  be 
a  few  vesicles  on  it.  Over  the  surface  of  the  cornea,  but  some- 
times confined  to  some  one  district  of  it,  there  are  a  number  of 
minute. vesicles,  some  shreds  of  epidermis — the  remains  of  rup- 
tured vesicles— and  round,  grayish-white  superficial  infiltrations, 
not  larger  than  a  pin's  head.  The  mucous  membrane  of  the 
nostrils  is  also  apt  to  be  attacked,  causing  swelling  of  it,  with 
much  secretion  and  the  formation  of  scabs. 

Treatment  at  an  early  stage,  before  the  vesicles  have  burst,  or 
the  loss  of  substance  has  become  infiltrated,  consists  in  protection 
of  the  eye  ;  and,  when  infiltration  has  set  in,  in  disinfection  with 


THE   CORNEA.  203 

protection.  If  the  vesicles  give  great  pain,  they  may  be  rup- 
tured by  dusting  a  little  calomel  into  the  eye  or  by  brushing  it 
with  a  camel's-hair  pencil  wet  with  solution  of  boracic  acid,  after 
which  a  well-fitting  antiseptic  bandage  is  applied.  Cocaine  is 
valuable  in  these  cases,  for  relief  of  the  pain.  Atropine  and 
warm  fomentations  should  also  be  employed,  and  a  weak  Pagen- 
stecher's  ointment  is  of  use  in  some  cases.  Where  the  nostrils 
are  affected,  weak  sublimate  or  other  antiseptic  washes  should  be 
applied  to  the  Schneiderian  mucous  membrane. 

Thread-like  Keratitis  (Fiidchen-Keratitis). — Of  this  form  of 
keratitis  I  have  not  as  yet  seen  a  case,  nor  has  one  been  recorded 
except  by  German  writers.  Its  name  is  due  to  the  fine  threads, 
like  twisted  spun-glass,  several  of  which  hang  from  the  surface  of 
the  cornea  and  give  the  condition  its  characteristic  appearance. 
These  threads  never  reach  a  length  of  more  than  3  or  4  mm. 

DiflTerent  views  are  held  as  to  the  mode  of  origin  of  the 
threads.  Fischer  and  Uhthoflf*  have  observed  that  small  vesi- 
cles with  clear  or  turbid  contents  appear  in  groups  upon  part  of 
the  cornea,  then  burst,  and  from  the  centre  of  each  resulting 
depression  a  thread  hangs  out.  The  onset  of  the  vesicles  is 
accompanied  by  much  pain  and  photophobia,  and  probably  has 
its  cause  in  some  affection  of  the  fifth  nerve.  The  duration  of 
an  attack  is  usually  short,  but  there  may  be  several  relapses 
at  brief  intervals,  and  finally  the  process  ceases  without  perma- 
nent damage  to  the  cornea.  These  same  authors  hold  that  the 
threads  are  composed  of  the  peculiar  fibrinous  contents  of  the 
vesicles.  Leber  f  does  not  believe  that  they  consist  of  material 
from  the  substance  of  the  cornea,  but  that  they  are  either  a 
fibrinous  or  mucilaginous  product  from  the  conjunctiva,  which 
readily  adheres  to  a  small  loss  of  substance  on  the  cornea.  I 
should  think,  if  this  explanation  were  the  true  one,  the  cases 
would  be  more  numerous.     C.   Hess's  investigations  t  lead  him 

*  Bericht  d.  Ophthal.  Gesellsch.,  1889. 
fBerichtd.  Ophth.  Gesellsch.,  1882  and  1889. 
X  A.  von  Graefe's  A?x-7iiv,  xxxviii,  part  1,  p.  160. 


204  DISEASES   OF   THE   EYE. 

to  think  that  the  corneal  epithelium  is  the  chief  component  of 
the  threads,  and  that  a  peculiar  diseased  state  of  this  epithelium 
is  a  condition  antecedent  to  the  appearance  of  the  vesicles  and 
threads. 

Treatment. — Protection  of  the  eye  with  a  bandage.  Atropine. 
Yellow  oxide  of  mercury  ointment  put  into  the  eye.  Warm 
fomentations. 

Bullous  Keratitis. — Bullse  very  rarely  form  on  the  cornea. 
They  are  never  the  primary  condition,  but  depend  on  an  inter- 
stitial diseased  process  in  the  cornea.  This  latter  may  itself  be 
a  primary  disease,  but  more  commonly  it  is  secondary  to  deep 
changes  in  the  eye,  such  as  absolute  glaucoma,  iridocyclitis,  etc. 
The  formation  of  a  bulla  is  attended  by  much  pain  and  photo- 
phobia, which  disappear  so  soon  as  the  bulla  ruptures.  One,  or 
more  than  one,  bulla  may  form  at  a  time.  After  a  day  or  two 
they  rupture,  and  their  walls  then  hang  in  shreds  from  the  sur- 
face of  the  cornea,  and  the  seats  of  the  bullae  present  shallow 
depressions.  These  losses  of  substance  heal  without  leaving  any 
permanent  opacity.  After  an  interval  of  days  or  weeks,  another 
crop  of  bullse  appears  and  runs  the  same  course. 

Treatment. — The  bullse  should  be  opened,  and  their  walls 
snipped  away  with  a  scissors,  and  a  bandage  applied.  The 
recurrent  attacks  may  cease  after  a  length  of  time;  but,  so  far 
as  treatment  can  influence  them,  it  can  only  be  by  relieving  the 
process  in  the  cornea  which  gives  rise  to  them.  If  it  be  a 
primary  process,  warm  fomentations,  atropine,  and  a  bandage, 
with  remedies  directed  to  correction  of  any  fault  in  the  general 
state  of  the  health  which  may  exist,  are  suitable ;  or  if,  as  is 
more  common,  a  deep  ocular  process  (glaucoma,  etc.)  be  the 
cause,  the  recognized  treatment  for  this  latter  must  be  adopted. 

Dendriform  (ofw5/>ov,  a  tree)  Keratitis. — This  is  a  rare  affec- 
tion, to  which  attention  was  first  drawn  by  Hansen  Grut, 
of  Copenhagen.  It  is  a  very  superficial  and  chronic  ulceration, 
with  but  little  infiltration  of  its  margins  or  floor,  and  presenting 
the  appearance  of  a  fine  groove  on  the  cornea.  It  spreads, 
chiefly  over  the  central  region    of  the  cornea,  by  throwing  out 


THE   CORNEA.  205 

branches  on  either  side.  The  pain  and  irritation  is  sometimes 
severe,  and  again  but  slight  or  quite  wanting.  Some  permanent 
opacity  often  remains  when  cure  has  been  effected. 

The  Cause  has  not  been  definitely  ascertained,  but  the  peculiar 
progress  of  the  affection  renders  it  almost  certain  that  some 
special  fungus  is  engaged. 

Treatment. — Scraping  with  a  sharp  spoon,  with  the  subsequent 
application  of  1  in  1000  solution  of  corrosive  sublimate  to  the 
cornea,  is  recommended  by  some,  and  the  actual  cautery  is  of 
great  use.  But  I  am  inclined  to  think,  from  my  experience  with 
the  last  few  cases  of  the  disease  I  have  had  under  my  care,  that 
the  application  of  absolute  alcohol  affords  the  most  certain  and 
rapid  cure.  I  soak  a  bit  of  lint  in  the  alcohol  and  scrub  the 
surface  of  the  cornea  with  it.  This  may  require  to  be  repeated 
two  or  three  times. 

(6)    NON-ULCERATIVE    INFLAMMATIONS     OF     THE    CORNEA. — 

Abscess. — This  affection  is  on  the  border-land  between  the 
ulcerative  and  non-ulcerative  inflammations  of  the  cornea ;  for 
in  one  case  it  will  result  in  an  ulcer — usually  the  ulcus  serpens — 
while  again  it  will  run  its  course  without  ulceration.  The 
abscesses  which  are  seated  in  the  more  superficial  layers  are 
those  which  go  on  to  ulceration  ;  those  in  the  deeper  layers  are 
less  likely  to  do  so. 

Abscess  differs  from  infiltration  in  that  the  pus  which  forms 
it  destroys  the  true  corneal  tissue — fibrilla?  and  fixed  cor- 
puscles— and  does  not  merely  lie  between  them. 

Signs  and  Symptoms. — The  appearance  presented  is  that  of  a 
yellowish  circumscribed  opacity,  more  intense  at  its  margin  than 
at  its  centre,  seated  at  or  near  the  middle  of  the  cornea,  and 
surrounded  by  a  light  gray  zone.  It  is  usually  round  in  shape, 
but,  when  situated  near  the  edge  of  the  cornea,  it  is  apt  to  be 
crescentic.  The  surface  of  the  cornea,  just  over  the  abscess,  is 
at  first  a  little  elevated  over  the  general  surface,  but  later  on 
becomes  flattened,  owing  to  a  falling-in  of  the  normal  layers 
anterior  to  the  abscess;  and  the  epithelium  of  the  flattened 
part  has  a  dull,  breathed-on  look.     The  rest  of  the  cornea  may 


206  DISEASES   OF   THE   EYE. 

also  lose  its  brilliancy,  although  in  a  much  less  degree.  Hy- 
popyon and  iritis  are  constant  attendants  upon  corneal  abscess. 
There  is  much  injection  of  the  conjunctival  and  ciliary  blood- 
vessels. Severe  pain  in  and  about  the  eye  and  blepharospasm 
are  common.  Occasionally,  a  corneal  abscess  will  be  attended 
by  but  little  pain  or  other  irritation. 

Progress. — The  abscess  spreads  through  the  cornea,  usually  in 
some  one  direction  ;  and  this  direction  is  indicated  by  the  yel- 
lowish opacity  being  more  intense  at  the  advancing  side  of  the 
abscess.  Before  long,  if  the  abscess  be  superficial,  the  layers 
of  cornea  covering  it  come  away,  and  the  condition  is  changed 
into  that  of  the  ulcus  serpens,  already  described.  The  deeper 
abscesses  spread  through  the  cornea  more  or  less  widely,  and 
ultimately  become  absorbed,  without  having  caused  ulceration. 
But  even  these  abscesses  leave  considerable  opacity  behind.  Of 
the  two,  the  process  which  ends  in  ulceration  is  the  more  common. 

Etiology. — Abscess  is  the  result  of  infection  of  the  cornea  with 
pyogenic  organisms,  which  reach  it  either  from  without,  through 
some  traumatic  loss  of  substance  of  the  corneal  epithelium,  or 
from  within,  by  the  agency  of  the  blood.  The  micro-organisms 
which  are  introduced  through  a  superficial  loss  of  substance 
may  either  have  been  present  on  the  foreign  body  which  pro- 
duced the  injury,  or  they  may  have  been  present  in  the  con- 
junctival sac.  Infection  through  the  blood  is  occasionally  seen 
in  some  acute  exanthematous  diseases,  such  as  scarlatina,  mea- 
sles, and  smallpox ;  more  especially  in  the  latter,  in  its  con- 
valescent stage. 

Treatment. — Atropine,  warm  fomentations,  and  a  bandage. 
But,  if  these  mild  measures  do  not  in  a  day  or  so  arrest  the 
progress  of  the  abscess,  resort  must  be  had  to  the  actual  cautery. 

Diffuse  Interstitial,  or  Parenchymatous,  Keratitis. — This 
affection  occurs,  most  commonly,  between  the  ages  of  five  and 
fifteen. 

It  commences  at  some  one  part  of  the  margin  as  a  light 
grayish  opacity,  accompanied  with  slight  injection  of  the 
ciliary  vessels.      The  rest  of  the  corneal  margin  soon  becomes 


THE   CORNEA.  207 

similarly  affected  ;  and  then,  gradually,  the  opacity  extends  con- 
centrically into  the  cornea,  or  does  so  by  sending  in  processes 
which  afterward  become  confluent.  In  this  way  the  whole 
cornea  becomes  affected  by  degrees ;  and  its  epithelium  acquires 
the  breathed-on,  or  ground-glass  appearance,  which  is  seen,  also, 
in  acute  glaucoma.  The  opacity  lies  in  the  deep  layers  of  the 
true  cornea,  and  is  slightly  more  intense  in  spots  here  and  there. 
It  is  sometimes  only  a  very  light  cloud,  while  again  the  cornea 
may  be  so  opaque  as  to  render  the  iris  quite  invisible.  When 
the  whole  cornea  has  become  opaque,  it  begins  to  clear  up  at  the 
margin,  and  the  central  portion  becomes  even  more  opaque  than 
the  margin  had  ever  been ;  a  fact  which  shows  that  the  very 
cells  which  entered  the  cornea  at  its  margin  have  advanced 
to  its  centre.  The  clear  margin  gradually  increases  in  width, 
until  only  a  rather  intense  central  opacity  is  left.  This  central 
opacity  slowly  breaks  up  and  becomes  absorbed,  but  not  always 
completely ;  and  then  considerable  and  permanent  impairment 
of  vision  may  remain.  Occasionally,  the  opacity  commences 
in  the  centre  of  the  cornea,  and  the  margin  remains  clear 
all  through.  Again,  a  very  intense  vascularization  (the  so- 
called  "  salmon  patch  ")  may  gradually  occupy  the  whole  cornea, 
following  the  progress  of  the  opacity.  There  is  no  tendency  to 
ulceration  in  this  affection  of  the  deep  layers. 

The  affection  is  often  accompanied  by  a  good  deal  of  pain 
and  blepharospasm,  especially  in  the  vascular  forms.  It 
is  very  liable  to  be  complicated  with  iritis,  or  even  with 
iridocyclitis,  and  herein  lies  its  greatest  danger.  The  iritis  is 
usually  of  the  serous  'form,  but  may  be  plastic,  and  opacities 
in  the  vitreous  humor  often  result  from  it.  Exudative 
choroiditis  and  optic  neuritis,  also,  very  occasionally  com- 
plicate it.  The  tension  of  the  eyeball  in  these  cases  may  be 
much  diminished  for  a  time. 

The  acute  stage  of  the  disease  lasts  from  six  to  eight  weeks,  or 
longer.  But  the  entire  process  may  not  be  completed  for  many 
months,  and  in  one  case  which  I  saw  the  opacity  did  not  begin 
to  clear  away  for  eleven    mouths   after   the   cornea   was   first 


208  DISEASES   OF   THE   EYE. 

attacked,  the    whole   process  extending   over    a  period  of  two 
years. 

Both  eyes  invariably  become  affected,  although  not  always 
at  the  same  time,  the  second  eye  often  not  becoming  attacked 
until  the  inflammation  in  the  first  has  made  some  progress,  or, 
perhaps,  not  until  it  has  undergone  cure.  It  is  important  to 
acquaint  the  patient,  or  his  parents,  with  the  likelihood  of  this 
course  of  events  in   the  very  commencement  of  his  treatment. 

Diffuse  interstital  keratitis  occurs  also  in  adults,  but  I 
have  never  seen  it  in  persons  of  over  thirty  or  thirty-five 
years  of  age.  These  adult  cases  present  a  greater  variety  of 
type  than  those  in  children,  and,  on  the  whole,  they  are  less 
severe  in  character.  Most  commonly,  one  eye  alone  becomes 
diseased,  the  degree  of  opacity  is  often  slight,  the  extent  of 
diseased  cornea  limited,  the  duration  of  the  process  compara- 
tively short,  and  the   complete  clearing-up  relatively  frequent. 

Causes. — The  affection  is  more  common  in  girls  than  in  boys, 
and  most  frequently  appears  during  second  dentition,  when  the 
upper  incisors  are  being  cut,  or  at  puberty.  It  depends  upon 
some  serious  derangement  of  the  general  nutrition  ;  and  this,  in 
over  fifty  per  cent,  of  the  cases,  is  inherited  syphilis,  a  fact 
which  was  first  pointed  out  by  Mr.  Jonathan  Hutchinson.  The 
children  are  generally  thin,  anaemic,  and  of  stunted  growth; 
with  flat  nose,  cicatrices  at  the  angles  of  the  mouth,  often  more 
or  less  deaf,  and  the  peculiarities  of  the  incisor  teeth,  so  well 
known  from  Mr.  Hutchinson's  description,  are  present  in  about 
one-half  of  the  cases. 

Occurring  in  adults,  the  affection  is  rarely  due  to  inherited 
syphilis,  although  acquired  lues  may  sometimes  be  taken  as 
its  cause  ;  while,  again,  it  will  often  be  impossible  to  assign  any 
origin  for  it  other  than  the  universal  one  of  exposure  to  cold, 
etc. 

Prognosis. — In  children,  in  view  of  the  possibility  of  an 
incomplete  clearing  of  the  cornea  and  the  irregularity  of  its 
surface  which  the  process  may  cause,  as  well  as  of  the  serious 
complications  liable  to   supervene  and  which  may  completely 


THE   CORNEA.  209 

annihilate  vision,  the  prognosis  must  be  guarded — although  by 
no  means  hopeless — in  those  cases  where  the  opacity  is  very 
intense  or  where  there  is  much  vascularity.  Yet  in  the  milder 
cases  a  very  favorable  prognosis  may  be  given.  I  have  never 
seen  the  affection  recur,  but  it  is  said  to  do  so  very  rarely. 

In  adults,  as  stated,  the  prognosis  is  much  more  favorable. 
Treatment. — In  the  early  stages  no  irritants  should  be 
locally  applied.  Atropine  is  important  for  the  prevention  of 
iritis  or  of  posterior  synechise ;  and  the  use  of  warm  moisture, 
in  the  form  of  poultices  or  fomentations,  promotes  vascu- 
larization and  hastens  absorption  of  the  cellular  elements, 
which  form  the  opacity.  When  the  acute  stage  is  ended, 
the  yellow  precipitate  ointment  may  be  employed  with  benefit 
for  stimulating  the  absorbents  to  carry  off  the  remains  of 
the  opacity.  Massage  may  be  used  with  advantage  in  both 
stages,  to  disperse  the  infiltration.  In  the  severe  cases  I 
would  advise  a  course  of  mercurial  inunctions  continued  for 
several  weeks,  care  being  taken  not  to  allow  stomatitis  to 
exceed  very  moderate  bounds.  In  mild  cases  a  tonic  plan 
of  treatment,  with  iodide  of  iron  and  cod-liver  oil,  is  the  most 
suitable.    ' 

In  adults,  where  it  is  desirable  to  use  mercurial  treatment, 
a  good  method  is  the  hypodermic  injection  of  perchloride  of 
mercury,  ^  to  ^V  g""-  ^^^^  ^  ^^1-  From  this  I  have  had 
satisfactory  results,  but  mercurial  inunctions  also  answer  well 
and  are  less  painful. 

Counter-irritation,  in  the  form  of  blisters  to  the  temples  or  a 
seton  in  the  scalp,  is  extensively  employed  by  some  surgeons. 
I  have  never  adopted  this  treatment,  as  I  doubt  its  value,  and  am 
loath  to  add  a  worry  to  the  troubles  inseparable  from  so  weari- 
some a  disease. 

Keratitis  Punctata  is  the  name  commonly  given  to  a  condi- 
tion which  occurs  in  cyclitis,  in  irido-cyclitis,  and  in  sympathetic 
ophthalmitis  (Chap.  X).  It  is  never  a  primary  disease  of  the 
cornea. 

It   is   due   to   the  deposit  of  minute  beads  of  lymph  on  the 
18 


210  DISEASES   OF   THE   EYE. 

membrane  of  Descemet,  which  gives  to  the  affected  part  of 
the  cornea  a  finely  dotted  appearance.  The  lymph  is  usually 
found  only  on  the  lower  quadrant  of  the  cornea — because 
it  gravitates  to  the  lowest  part  of  the  anterior  chamber — 
in  a  triangular  space,  of  which  the  base  is  at  the  corneal 
margin,  while  its  apex  is  directed  toward  the  centre  of  the 
cornea.  This  triangular  shape  is  the  result  of  the  motions  of 
the  eyeball,  w4iich  throw  the  lymph  beads  against  the  cornea. 

When  the  process  which  gives  rise  to  this  condition  passes  off 
rapidly,  the  cornea  is  restored  to  its  normal  state;  but  when 
the  primary  disease  is  chronic,  the  nutrition  of  the  true  cornea, 
in  the  triangular  space  corresponding  to  the  deposit  of  lymph, 
is  apt  to  be  interfered  with — by  reason  of  degeneration  of  the 
endothelium  of  Descemet's  membrane,  which  protects  the  cornea 
from  the  aqueous  humor — so  that  it  becomes  intensely  and  per- 
manently opaque. 

Some  authors  do  not  use  the  term  Keratitis  punctata  for  the 
foregoing  condition,  but  reserve  it  for  some  cases  of  inter- 
stitial keratitis  which  present  a  spotted  or  dotted  appearance. 

Sclerotizing  Opacity  of  the  cornea  sometimes  complicates 
scleritis,  affecting  the  cornea  in  the  neighborhood  of  the  scleral 
affection,  but  not  extending  more  than  2  to  3  mm.  into  the 
cornea,  except  in  very  severe  cases.  It  is  an  intense  white 
opacity,  situated  in  the  true  cornea,  and  is  apt  to  remain  as 
a  permanent  opacity,  even  when  the  scleritis  undergoes  cure. 
In  such  cases  of  sclero-keratitis,  iritis  is  often  present. 

Treatment. — Warm  fomentations,  massage,  and  the  treatment 
of  whatever  diathesis  (rheumatism,  syphilis)  may  be  taken  as 
giving  rise  to  the  scleritis. 

Riband-like  Keratitis  (Transverse  Calcareous  Film  of  the 
Cornea;  Calcareous  Film  of  the  Cornea). — This  is  an  altera- 
tion which  occurs  chiefly  in  the  cornese  of  eyes  destroyed  by 
severe  intraocular  processes,  such  as  iridocyclitis,  sympathetic 
ophthalmitis,  glaucoma,  etc.  It  occupies  that  transverse  strip 
of  the  cornea  which  is  uncovered  in  the  commissure  of  the  eye- 
lids during  waking.     It  usually  commences  on  the  inner  margin 


THE   CORNEA.  211 

of  the  cornea,  but  soon  appears  at  the  outer  margin  and  advances 
from  each  direction  toward  the  centre,  where  the  two  sections 
join.  It  presents  the  appearance  of  a  grayish-brown  opacity,  with, 
in  many,  but  not  in  all,  cases, white  calcareous  deposits  in  and  under 
the  epithelium.  Magnus*  points  out  that  in  blind  eyes  which  are 
constantly  rolled  upward  the  opacity  is  found,  not  in  the  cen- 
tral transverse  section  of  the  cornea,  but  in  its  lower  third, 
and  from  this  circumstance  he  argues  that  the  chief  factor  for 
its  production  is  exposure  of  the  part  affected.  He  believes, 
moreover,  that  so  large  a  proportion  of  the  affected  eyes  having 
suffered  severely  in  their   general  nutrition  indicates  that  the 

Fig.  86.     (Pagenstecher.)  Fig.  87.     {Pagenstecher.) 


opacity  is   a  further   development   of   this  malnutrition.      He 
proposes  for  the  affection  the  name  Keratitis  trophica. 

ECTASIES   OF   THE   CORNEA. 

Staphyloma  Corneae  is  the  result  of  a  perforating  ulcer  of  the 
cornea.  This,  having  healed,  may  present  a  weak  cicatrix, 
which  becomes  bulged  forward  by  even  the  normal  intraocular 
tension  (Figs.  SQ  and  87).  If  the  iris  be  not  involved  in  this 
cicatrix,  the  anterior  chamber  will  be  made  deeper  (Fig.  87). 

Staphyloma  corneae,  in  which  the  iris  is  involved,  is  probably 
a  more  common  condition  than  the  above. 

*  Klin.  Monatshl.f.  Augenheilkunde,  February,  1883,  p.  45. 


212  DISEASES   OF   THE   EYE. 

\yhen  the  ulcer  is  large,  a  correspondingly  large  portion  of 
iris  is  liable  to  become  prolapsed  into  it  and  to  form  a  bulging 
mass  outside  the  eye.  This  may  burst  and  collapse,  and  a  flat 
cicatrix  may  be  formed.  Or,  if  it  do  not  rupture,  it  may  form 
what  is  termed  a  partial  staphyloma  of  the  cornea  and  iris,  the 
latter  becoming  consolidated  by  the  formation  of  a  layer  of  con- 
nective tissue  over  it. 

If  the  whole,  or  a  very  large  part,  of  the  cornea  be  destroyed 
by  an  ulcer,  the  iris  is  completely  exposed.  It  soon  begins  to  be 
covered  with  a  layer  of  lymph,  which  develops  into  an  opaque 
cicatricial  membrane.  Should  this  not  be  strong,  the  normal 
intraocular  tension  is  sufficient  after  a  time  to  make  it  bulge  ;  or, 
increased  intraocular  tension  may  arise  in  consequence  of 
further  changes  within  the  eye,  and  then  bulging  of  the  pseudo- 
cornea  more  surely  comes  on,  and  the  condition  is  termed  total 
staphyloma  of  the  cornea.  Sometimes  a  total  staphyloma  has  a 
lobulated  appearance,  owing  to  the  pseudo-cornea  having  some 
fibres  stronger  than  others,  and  hence  the  name  given  to  the 
condition,  from  (jza(fulri,  a  bunch  of  grapes.  Such  staphylomata 
are  apt  to  gradually  increase  to  a  very  large  size. 

Treatment. — In  cases  of  partial  staphyloma,  where  a  clear 
portion  of  the  cornea  remains,  an  iridectomy  is  frequently  indi- 
cated for  the  reduction  of  the  tension — so  that  further  bulging 
may  be  arrested — as  well  as  for  the  sake  of  the  artificial  pupil, 
which  may  improve  sight  in  cases  where  the  normal  pupil  is 
obliterated  by  corneal  opacity.  When,  sight  having  been  lost, 
the  staphyloma  is  very  bulging,  or  when  total  staphyloma  is 
present,  enucleation  of  the  eyeball  or  one  of  the  following  opera- 
tive measures  must  be  adopted. 

Abscission. — A  Beer's  cataract  knife  being  passed  through  the 
base  of  the  staphyloma,  with  its  edge  directed  upward,  the  upper 
two-thirds  of  the  staphyloma  are  separated  ofi",  while  the  remain- 
ing third  is  detached  by  means  of  a  scissors.  If  the  lens  be 
present,  it  must  now  be  removed.  The  wide  opening  becomes 
filled  up'with  granulations  and  cicatrizes  over. 


THE   CORNEA. 


213 


In  de  Wecker's*  method  the  openiDg  is  closed  with  conjunc- 
tival sutures.  He  begins  the  operation  by  separating  the  con- 
junctiva all  round  the  margin  of  the  cornea,  and  then  loosening  it 
from  the  eyeball  nearly  as  far  back  as  its  equator.  Four  sutures 
(a,  b,  c,  d),  of  different  colors,  are  then  passed  through  the  con- 
junctiva about  2  to  3  mm.  from  the  margin  of  the  wound,  as 
represented  in  Fig.  88.  In  order  to  keep  the  field  of  operation 
clear,  the  ends  of  two  of  these  sutures  are  laid  over  on  the  nose, 

Fig.  88. 


while  the  others  are  laid  over  on  the  temple.  The  staphyloma  is 
now  abscised,  and  the  sutures  drawn  together  and  tied.  The 
conjunctival  scar,  de  Wecker  states,  can  be  tattooed  in  the 
centre  at  a  later  period,  and  by  this  means  the  wearing  of  an 
artificial  eye  made  unnecessary. 

The  late  Mr.  G.  Critchett  proposed  the  following  method, 
which  has  met  with  much  approval :  The  base  of  the  staphy- 
loma is  transfixed  with  four  or  five  curved  needles  passed  from 
above   downward  at  regular  intervals  (Fig.  89),  the  punctures 


Chirurgie  Oculaire,  p.  188. 


214 


DISEASES   OF   THE    EYE. 


'J}'])]) 


and  counter-punctures  being  in  the  sclerotic,  at  points  half-way 

between  the  margin  of  the  sta- 
phyloma and  the  insertion  of 
the  recti  muscles.  With  a  sharp 
knife  the  staphyloma  is  now 
divided  horizontally,  the  inci- 
sion running  from  the  inser- 
tion of  the  external  rectus  to 
that  of  the  internal  rectus  ;  and 
then  the  two  halves  of  the  sta- 
phyloma are  abscised  with  scis- 
sors, the  line  of  abscission  lying 
some  2  mm.  from  the  points  of 
entrance  and  exit  of  the  needles.  The  latter  are  now  drawn 
through  and  the  sutures  tied,  so  that  the  edges  of  the  sclerotic 
may  be  applied  to  each  other  as  accurately  as  possible.  The 
resulting  stump  (Fig.  90)  is  capable  of  carrying  an  artificial  eye 
without  becoming  irritated. 

The  foregoing  and  other  methods  of  abscission  are  only  appli- 
cable where  the  tension  is  either  low  or  normal.  If  it  be  high, 
the  liability  to  intraocular  hemorrhage  during  the  operation 
makes  enucleation,  evisceration,  or  Mules'  operation,  more 
suitable  proceedings.  Indeed,  I,  and  probably  most  surgeons, 
would  now  employ  one  of 
the  two  latter  operations  in 
all  these  cases. 

Evisceration  (Exentera- 
tion) was  proposed  about 
the  same  time  by  Professor 
Graefe,  of  Halle*,  to  prevent 
death  from  meningitis  after 
the  removal  of  suppurating 
globes,  and  by  Mr.  Mules,! 
of  Manchester,  chiefly  to 
take   the   place  of  enuclea- 


FiG.  90. 


'n))M)?i' 


*  Centralblf.  Augenheilk.,  1884,  p.  378.     t^bid.,  1885,[p.  32. 


THE   CORNEA.  215 

tion  in  cases  of  sympathetic  ophthalmitis.  There  are  some  who 
are  opposed  to  its  employment  in  those  cases ;  but,  for  staphy- 
loma of  the  cornea,  it  cannot  meet  with  any  such  opposition. 

The  cornea  is  reaioved  by  making  an  incision  with  a  Graefe's 
knife,  so  as  to  include  one-half  of  the  corneo-scleral  margin,  and 
then  completing  the  circumcision  with  scissors.  All  the  con- 
tents of  the  globe  are  then  evacuated  by  means  of  Mr.  Mules' 
scoop,  care  being  taken  to  remove  the  choroid  unbroken  by 
carefully  peeling  it  from  the  sclerotic  margin  backward,  until 
it  is  only  held  at  the  lamina  cribrosa.  The  scoop  is  then  used 
to  lift  the  separated  unbroken  choroid  and  its  other  contents  out 
of  the  globe. 

Finally,  the  margins  of  the  sclerotico-conjunctival  wound 
are  drawn  together  with  a  few  points  of  suture.  The  whole 
proceeding  should  be  done  with  strict  antiseptic  precautions, 
chief  among  which  is  the  free  use  of  irrigation  with  a  1  in 
5000  solution  of  corrosive  sublimate  before,  duriug,  and  after 
the  operation,  the  interior  of  the  globe  being  most  carefully 
washed  out  with  the  solution  in  a  full  stream.  The  result 
is  a  good  and  freely  movable  stump  for  the  application  of 
an  artificial  eye. 

Mules'  Operation. — This  proceeding,  a  modification  of  the 
foregoing,  was  also  proposed  by  Mr.  Mules*  for  cases  of 
threatened  sympathetic  ophthalmitis,  and,  like  simple  eviscera- 
tion, has  not  yet  met  with  universal  acceptance  in  those  cases. 
Its  object  is  to  provide  a  still  better  stump  for  the  artificial  eye 
by  the  insertion  into  the  scleral  cavity  of  a  hollow  glass  ball, 
called  an  "Artificial  Vitreous  Humor."  It  is  performed  as 
follows  : — 

The  cornea  is  removed — the  conjunctiva  having  first  been 
freed  from  the  scleral  edge  toward  the  equator  of  the  eye- 
ball— and  the  contents  of  the  eyeball  evacuated,  as  in  simple 
evisceration.  The  opening  is  now  enlarged  vertically,  to 
admit  of  the  introduction   of  one  of  the  glass  spheres.      This 

*  Trans.  Ophthal  Soc,  Vol.  v,  p.  200. 


216  DISEASES   OF   THE    EYE. 

introduction  is  best  effected  by  means  of  a  special  instrument 
designed  for  the  purpose  by  Mr.  Mules.  The  spheres  are 
made*  in  several  sizes  to  suit  different  cases,  and  it  is  well 
not  to  use  the  largest  which  will  fit  into  any  given  eye.  The 
margins  of  the  sclerotic  opening  are  now  united  vertically  by 
some  points  of  interrupted  suture,  for  which  purpose  I  prefer 
silk  to  catgut,  as  the  latter  is  apt  to  undergo  absorption  before 
complete  union  has  taken  place.  The  conjunctival  opening 
is  then  closed  by  another  set  of  sutures  placed  at  right  angles 
to  the  sclerotic  line  of  closure.  Similar  antiseptic  precau- 
tions are  required,  as  in  simple  evisceration,  and  care  must 
be  taken  that  all  bleeding  in  the  cavity  has  ceased  before  the 
glass  sphere  is  inserted.  Before  the  lids  are  closed,  the  anterior 
surface  of  the  globe  is  well  covered  with  powdered  iodoform.  A 
firm  antiseptic  bandage  is  applied.  I  do  not  dress  the  eye  for 
forty-eight  hours,  and  after  that  once  every  twenty-four  hours, 
using  the  corrosive  sublimate  solution  freely  and  iodoform. 
There  is  generally  some  reaction,  consisting  of  chemosis, 
swelling  of  the  eyelids,  and  pain,  and  sometimes  these  symp- 
toms are  very  marked,  especially  if  rather  too  large  a  sphere 
have  been  employed.  In  the  course  of  a  week  or  so  this  all 
passes  off,  and  a  very  perfect  stump  is  obtained. 

To  prevent  excessive  reaction,  Mr.  Mules  burrows  into  the 
orbit  at  the  outer  side,  so  that  the  points  of  the  scissors  may 
penetrate  well  beyond  the  back  of  the  globe,  and  then  intro- 
duces deeply  a  drain  of  gold  wire,  such  as  is  used  by  dentists 
bringing  it  out  between  the  lids  at  the  outer  canthus.  An 
ice-bag  is  applied.     The  drain  is  left  in  about  three  days. 

The  danger  that  the  glass  sphere  may  get  broken  by  a  blow 
upon  the  eye  has  been  put  forward  as  an  objection  to  this 
method.  No  doubt  it  is  an  accident  which  may  occur,  and 
would  then  necessitate  the  enucleation  of  the  eye ;  but  no  case 
of  the  kind  has  as  yet  been  recorded,  although  the  operation  has 
been  in  use  for  seven  years.      Silver  spheres,  instead  of  those 

*  By  Messrs.  Armstrong,  of  Deansgate,  Manchester. 


THE  CORNEA.  217 

of  glass,  have  been  sometimes  employed  to  obviate  the  danger 
referred  to.  I  practice  this  method  a  great  deal,  and  I  can 
heartily  recommend  it.  The  only  trouble  I  have  had  with  it  is, 
that  sometimes  the  sclerotic  opening  does  not  close  well,  and 
the  glass  ball  has  to  be  removed.  The  case  then  becomes  one 
of  simple  evisceration. 

Conical  Cornea,  or  Keratoconus. — In  this  the  cornea  is 
altered  in  shape  to  that  of  a  cone.  The  change  is  due  to  a 
gradual  and  slowly  advancing  atrophic  process  in  the  cornea, 
especially  at  its  centre,  in  consequence  of  which  the  normal 
intraocular  tension  acts  on  it,  so  as  to  distort  it  into  the 
form  represented  in  Fig.  91.  The  cornea  remains  clear, 
except  sometimes  just  at  the  apex  of  the  cone,  where  a 
slight  nebula  may  be  present.  The 
condition  is  easy  of  diagnosis  in  its  ad- 
vanced stages  by  mere  inspection  of  the 
cornea,  especially  in  profile,  but  in  its 
commencement  it  may  not  be  so. 

In  the  early  stages,  when  the  light 
is  thrown  on  the  cornea  from  the  oph- 
thalmoscope mirror,  as  in  retinoscopy,  the  corneal  reflex  will 
be  noticed  to  be  smaller  at  the  centre,  owing  to  the  greater 
curvature  there.  Moreover,  a  dark  shadow,  circular  or  cres- 
centic  in  shape  according  to  the  incidence  of  the  light,  will 
be  seen  between  the  corneal  margin  and  centre ;  and,  finally, 
when  the  fundus  is  examined  its  details  will  be  seen  distorted. 

The  process  begins  in  early  adult  life,  progresses  slowly, 
never  leads  to  rupture  or  ulceration  of  the  cornea,  and, 
finally,  after  many  years,  ceases  to  progress,  but  does  not 
undergo  cure.  Both  eyes  are  apt  to  become  attacked,  one 
after  the  other.  The  disturbance  of  vision  is  very  great, 
owing  to  the  extreme  irregular  astigmatism  produced. 

Treatment. — In   the   early  stages,  or  in   slight  cases,  an  im- 
provement in   vision  may   be   obtained    by  means   of  concave 
spherical,   or    sphero-cylindrical    glasses;     for,   as   is    evident, 
the   change   in  shape  of   the   cornea   must   cause   the   eye   to 
19 


218  DISEASES   OF   THE   EYE. 

become  myopic.  At  a  later  period  these  glasses  are  of  little 
use.  Hyperbolic  lenses  have  been  employed,  but  although 
they  may  raise  the  acuteness  of  vision,  there  are  obvious 
difficulties  in  the  way  of  the  practical  every-day  use  of 
them.     A  stenopseic  slit  renders  assistance  in  some  cases. 

A  few  cases  are  reported  in  which  the  keratoconus  was 
much  reduced,  and  vision  greatly  bettered,  by  installations  of 
eseriue  and  the  application  of  a  pressure  bandage  continued 
for  several  months. 

But  it  is  upon  operative  measures  we  must  chiefly  rely  in  this 
affection  for  any  improvement  in  sight. 

Von  Graefe's  Method  consists  in  flattening  the  cornea  by 
the  production  of  an  ulcer  on  the  apex  of  the  cone,  and  the 
resulting  cicatricial  contraction.  From  the  surface  of  the 
cornea,  a  little  to  one  side  of  the  apex  of  the  cone,  a  morsel 
of  corneal  substance  is  removed  with  a  cataract  knife,  care 
being  taken  not  to  open  the  anterior  chamber.  On  the  second 
day  after  this  proceeding  the  wound  is  touched  with  mitigated 
lapis  (solid),  and  this  is  repeated  every  third  day  for  a  fort- 
night or  three  weeks.  Paracentesis  of  the  anterior  chamber 
is  then  performed  through  the  floor  of  the  ulcer,  and  the 
aqueous  humor  is  evacuated  every  second  day  for  a  week, 
after  which  the  healing  process  is  allowed  to  take  its  course. 
A  bandage  must  be  worn  during  the  whole  course  of  the  treat- 
ment. Finally,  when  the  contraction  and  subsequent  flattening 
are  completed,  a  narrow  iridectomy  may  be  necessary,  in 
consequence  of  the  central,  or  almost  central,  and  rather 
intense  corneal  opacity. 

In  Bader's  Method  a  small  elliptical  flap  of  the  cornea  at 
its  apex  is  removed,  and  the  margins  are  brought  together  by 
one  or  two  fine  sutures.  The  sutures  are  omitted  by  many 
surgeons  as  useless  and  as  liable  to  cause  irritation.  Opinion 
is  divided  as  to  whether  the  ellipse  should  lie  vertically  or 
horizontally  in  the  cornea.  Anterior  synechia  takes  place  in  a 
large  number  of  the  cases,  and  a  subsequent  optical  iridectomy 
is   always   required.      I   have   myself  no    experience    of    this 


THE   CORNEA.  219 

operatioD,  but  it  is  said  to  be  attended  with  unusual  risk 
of  suppuration  of  the  cornea,  going  on  to  destruction  of  sight. 

Sir  William  Bowman's  Method  consisted  in  cutting  a  disc 
on  the  apex  of  the  cornea  with  a  small  trephine,  and  then 
severing  this  disc  with  forceps  and  cataract  knife.  Cicatriza- 
tion of  the  wound  produces  the  desired  flattening  of  the  cone. 
Septic  infection  is  here  also  a  danger,  although  it  has  not  come 
under  my  own  observation. 

I  have  myself,  in  one  case,  employed  the  electro-cautery 
to  produce  the  desired  loss  of  substance  on  the  apex  of  the 
cone,  but  I  am  not  as  yet  in  a  position  to  speak  of  the 
ultimate  result.  I  believe  that  others  have  used  the  electro- 
cautery with  good  result  for  sight.  The  proceeding  is  free  from 
all  risk  of  septic  infection. 

With  the  same  object  some  surgeons  have  had  recourse  to 
Multiple  Puucturings  of  the  apex  of  the  cone  with  a  fine 
cataract  needle.  The  summit  of  the  cone  is  transfixed  from 
three  to  six  times  at  each  sitting,  and  this  may  be  repeated 
at  intervals  of  two  weeks  or  more.  The  first  effect  of  the 
punctures  is  to  allow  some  of  the  aqueous  humor  to  escape, 
and  then  the  eye  is  firmly  supported  with  a  bandage.  The 
pupil  is  kept  under  the  influence  of  eserine.  Eventually,  a 
network  of  cicatrical  tissue  forms,  which  flattens  the  cone  with- 
out giving  rise  to  much  corneal  opacity. 

Tumors  of  the  Cornea. 
Primary  tumors  of  the  cornea  are  extremely  rare.  Epi- 
thelioma and  sarcoma  have  their  origin,  not  in  the  cornea,  but  in 
the  limbus  conjunctivae  (p.  119).  Dermoid  tumors  are  usually 
seated  partly  on  the  conjunctiva  and  partly  on  the  cornea 
(p.  119).  Yet  a  very  few  cases  of  epithelioma  and  of  fibroma 
are  recorded  as  taking  their  origin  in  the  cornea. 

Injuries  of  the  Cornea. 
Foreign  Bodies  in  the  Cornea,  such  as  morsels  of  iron,  stone, 
coal,  etc.,  are  among  the  most  common  accidents  of  the  entire 


220  DISEASES   OF  THE   EYE. 

body.  The  pain  caused  by  these  foreign  bodies  is  very  consider- 
able, as  may  be  imagined  when  the  rich  nervous  supply  of  the 
cornea  is  remembered. 

The  dangers  which  may  follow  on  the  presence  of  a  foreign 
body  in  the  cornea,  depend  partly  upon  the  infection  or  non-in- 
fection of  the  foreign  body,  and  partly  upon  the  depth  at  which 
it  is  buried  in  the  cornea.  The  deeper  a  foreign  body  lies,  the 
more  difficult  will  be  its  removal,  and  the  greater  must  be  the 
laceration  of  the  cornea  caused  by  its  removal.  A  foreign  body 
which  carries  infection  upon  it,  will  be  more  likely  to  set  up 
serious  inflammatory  reaction,  than  one  which  is  aseptic  or  nearly 
so.  For  this  reason,  it  is  important  to  ascertain,  if  possible,  the 
origin  of  the  foreign  body,  although  an  apparently  aseptic  origin 
must  not  set  all  suspicion  on  this  point  at  rest. 

Many  foreign  bodies  are  so  small  as  to  defy  detection,  until 
the  cornea  is  searched  with  the  oblique  light,  an  aid  which 
should  always  be  made  use  of,  whenever  the  symptoms  or 
history  in  the  remotest  way  suggest  the  presence  of  a  foreign 
body. 

A  foreign  body  which  lies  only  in  the  epithelium,  or  in  the 
superficial  layers  of  the  cornea,  is  easily  removed.  The  eye 
having  been  thoroughly  cocainized,  the  patient  is  seated,  and 
leans  his  head  against  the  chest  of  the  surgeon,  who  stands  be- 
hind him.  With  the  index-finger  of  the  left  hand  the  surgeon 
then  lifts  the  upper  lid  of  the  injured  eye,  pressing  the  margin 
of  the  lid  upward  and  backward,  while  with  the  second 
finger  he  depresses  the  lower  lid  in  a  similar  manner,  and 
between  these  two  fingers  he  can,  to  a  great  extent,  restrain 
the  motions  of  the  eyeball.  The  foreign  body  is  now  to  be 
pricked  out  of  the  cornea  with  a  special  needle,  with  as  little 
injury  of  the  general  surface  as  possible,  the  patient  all  the 
while  directing  his  gaze  steadily  at  some  given  point.  If  the 
foreign  body  be  deep  in  the  layers  of  the  cornea,  it  must  be  dug 
out,  as  it  were  ;  and   a  minute  gouge  is  made  for  this  purpose. 

Care  must  be  taken  not  to  infect  the  cornea  in  the  removal 
of  a  foreign  body,   and  consequently   thorough  antiseptic   pre- 


THE   CORNEA.  221 

cautions  must  be  taken.  After  the  foreign  body  is  removed 
the  place  where  it  was  seated  should  be  washed  with  a  1 
in  5000  solution  of  corrosive  sublimate.  A  bandage  is 
worn  until  the  epithelium  is  regenerated — i.e.  for  several 
days. 

Every  surgeon  and  general  practitioner  should  possess  the 
two  small  instruments  required  for  the  removal  of  superficial 
corneal  foreign  bodies,  and  should  understand  the  use  of  them. 

The  magnet  is  of  no  use  whatever  for  the  removal,  even  of 
superficially  seated  foreign  bodies  of  steel  or  iron  in  the  cornea. 

Sometimes  a  foreign  body  in  the  cornea  will  be  so  long  as  to 
protrude  somewhat  into  the  anterior  chamber,  and  there  is 
danger  that  in  the  attempts  at  removal  it  may  be  pushed 
further  on,  and  fall  into  the  anterior  chamber.  Here  it  is 
necessary  to  pass  a  keratome  through  the  cornea,  and  behind 
the  foreign  body,  so  as  to  provide  a  firm  base  against  which  to 
work  ;  or,  the  keratome  may  be  made  to  push  the  foreign  body 
forward. 

Simple  Traumatic  Losses  of  Substance  of  the  surface  of  the 
cornea,  involving  the  most  anterior  layers  of  the  true  cornea,  or 
perhaps  merely  the  epithelium,  are  very  common  from  rubs  or 
scratches  with  branches  of  trees,  finger-nails  etc.,  etc.  These 
injuries  heal  readily  by  protecting  the  eye  with  a  bandage  ;  but 
when  neglected,  or  if  septic  matter  have  been  introduced  when 
the  injury  occurred,  or  if  it  be  present  in  the  conjunctiva  or 
lachrymal  sac,  these  losses  of  substance  are  capable  of  forming  the 
starting-point  of  corneal  abscess,  ulcus  serpens,  etc. 

Opacities  of  the  Cornea. 
Nebula,  Macula,  Leucoma. — These  terras  are  applied  to  opac- 
ities in  the  cornea,  of  varying  degrees,  the  result  of  some  diseased 
process,  or  consequent  upon  an  injury.  The  first  term  is  used 
for  very  slight  opacities,  often  discoverable  only  with  oblique 
illumination.  Macula  indicates  a  more  intense  opacity,  recog- 
nizable by  daylight.  Leucoma  is  a  completely  non-translucent 
and  intensely  white  opacity,  the  result  always  of  an  ulcer,  which 


222  DISEASES   OF   THE   EYE. 

has  destroyed  most  of  the  true  corneal  tissue  at  the  affected  place ; 
indeed,  it  is  often  the  result  of  an  ulcer  which  has  eaten  its  way 
through  the  cornea.  In  these  latter  cases  the  iris  may  have 
become  adherent  in  the  corneal  cicatrix,  and  then  the  term  leu- 
coma  adhnerens  is  employed. 

Very  often,  eyes  with  a  nebulous  condition  of  the  cornea  of 
old  standing  are  myopic.  It  is  probable  that  this  myopia  is  pro- 
duced by  the  habitual  close  approximation  of  objects  to  the  eye, 
owing  to  the  diminished  acuteness  of  vision  from  the  opacity  of 
the  cornea. 

Treatment. — Little  or  nothing  can  be  done  to  reduce  these 
opacities.  In  slight  and  fresh  cases,  massage  may  render  them 
less  intense. 

In  nebulous  cornea  a  stenopseic  apparatus  often  improves  the 
sight.  This  consists  of  a  metal  plate  with  a  small  central  hole 
or  slit,  which  is  placed  before  the  patient's  eye  in  a  spectacle 
frame.  By  this  arrangement  a  large  portion  of  the  rays  which 
pass  through  irregular  parts  of  the  cornea,  and  which  merely 
confuse  the  sight,  is  cut  off.  Where  myopia  is  present  the  suit- 
able concave  glasses  for  distant  vision  should  be  prescribed. 

The  Operation  of  Tattooinrj  was  first  proposed  by  de  Wecker, 
and  is  a  valuable  proceeding  for  improvement  of  the  appearance 
of  the  eye  in  cases  of  leucoma. 

But  it  is  also  an  extremely  useful  method  for  the  improvement 
of  the  sight  in  certain  cases  of  nebula  of  the  cornea,  where  the 
nebula  occupies  only  part  of  the  pupillary  area  of  the  cornea. 
In  these  cases  much  disturbance  of  sight  is  caused  by  the  dis- 
persion of  the  light  which  makes  its  way  through  the  nebula ; 
and  when,  by  tattooing  the  scar,  all  light  is  prevented  from  get- 
ting through,  brighter  and  distincter  vision  is  enjoyed  with  the 
part  of  the  cornea  opposite  the  pupil,  which  is  absolutely  clear. 

In  the  case  of  a  leucoma,  either  the  whole  surface  of  the 
leucoma  may  be  tattooed,  or  only  part  of  it,  e.g.,  its  centre,  in 
order  to  represent  a  pupil. 

The  material  used  is  fine  India  ink,  rubbed  into  a  very 
thin  paste.      The  eye   having  been   cocainized,  the  leucoma   is 


THE   CORNEA.  223 

spread  over  with  this  paste,  and  then  covered  with  innumer- 
able punctures  by  means  of  de  Wecker's  multiple  tattooing- 
needle,  each  stab  of  which  carries  into  the  corneal  tissue 
some  of  the  black  pigment.  The  coloration  continues  suffi- 
ciently intense  for  some  months,  but  then  often  begins  to 
get  pale,  owing,  probably,  to  the  pigment  falling  out  of  the 
punctures.  A  better  method  of  tattooing,  by  which  the  pig- 
mentation lasts  longer,  is  performed  with  de  Wicker's  single 
grooved  needle.  The  pigment  is  placed  in  the  groove  of  the 
instrument,  which  is  then  passed  into  the  true  cornea,  a  long 
canal  being  made  in  a  plane  parallel  to  its  surface.  On 
withdrawal  of  the  needle  the  pigment  remains  behind.  A 
large  number  of  such  canals  must  be  made  in  close  proximity 
to  each  other,  until  the  desired  intensity  of  color  is  obtained. 

In  cases  where  the  whole  cornea  is  leucomatous,  and,  con- 
sequently, where  no  restoration  of  sight  can  be  obtained  by 
means  of  an  artificial  pupil,  Transplantation  of  a  Portion  of 
Clear  Cornea  from  a  rabbit's  eye,  or  from  a  freshly  enucleated 
human  eye,  has  been  repeatedly  performed  by  ophthalmolo- 
gists in  various  parts  of  the  world.  Very  many  of  these 
operations  have  been  perfectly  successful  in  a  surgical  sense, 
i.  e.,  in  so  far  as  the  healing-in  of  the  transplanted  flap  is  con- 
cerned ;  but,  with  two  exceptions,  they  all  ended  in  disap- 
pointment, in  consequence  of  the  flap  not  retaining  its  trans- 
parency. In  the  course  of  a  week  or  two  the  transplanted 
portion  invariably  became  as  opaque  as  the  leucoma  had  been 
before.  The  mode  of  proceeding  consisted  in  removing  a 
portion  of  the  leucoma  with  a  trephine,  and  then,  with  the 
same  instrument,  cutting  a  disc  out  of  the  clear  cornea  to 
be  utilized,  and  inserting  it  into  the  opening  in  the  leucoma. 

Various  theories  were  formed  to  account  for  the  occurrence 
of  the  opacity  in  the  transplanted  flap,  but   into  all  of  these 
it  is  unnecessary  to  enter.     Von  Hippel*  came  to  the  conclu- 
sion  that   the   onset   of  the  opacity  was   due  to  the  entrance 
of    the    aqueous   humor    into    the    substance    of   the    cornea, 

*Bericht  der  Ophthal.  Gesellschaft  zu  Heidelberg,  1886,  p.  54. 


224  DISEASES   OF   THE   EYE. 

owing  to  the  solution  of  continuity  in  its  posterior  epithelium ; 
Leber's  experiments*  having  shown  that,  unless  this  epithe- 
lial layer  be  intact,  the  transparency  of  the  cornea  cannot 
be  maintained.  Von  Hippel,  acting  on  this  theory,  applied 
a  trephine  to  the  leucoma  as  deep  as  the  posterior  elastic 
lamina,  and  then  dissected  off  the  superficial  layers  contained 
within  the  ring,  leaving  only  the  posterior  elastic  lamina 
and  posterior  epithelium.  With  the  same  trephine  he  then 
excised  a  disc  of  its  entire  thickness  from  a  rabbit's  cornea, 
and  applied  it  to  the  wound.  Iodoform  was  dusted  over  this 
and  a  bandage  applied.  Healing  took  place  readily,  and, 
twenty  months  afterward,  the  flap  continued  transparent,  and 
vision  =  ^2_o_^  You  Hippel  has  had  some  other  successful 
cases. 

Sclerotizing  Opacity  of  the  cornea  sometimes  complicates 
scleritis,  affecting  the  cornea  in  the  neighborhood  of  the 
scleral  affection,  but  not  extending  more  than  2  to  3  mm. 
into  the  cornea,  except  in  very  severe  cases.  It  is  an  intense 
white  opacity,  situated  in  the  true  cornea,  and  is  apt  to  remain 
as  a  permanent  opacity,  even  when  the  scleritis  undergoes  cure. 
In  such  cases  of  sclero- keratitis,  iritis  is  often  present. 

Treatment. — Warm  fomentations,  massage,  and  the  treatment 
of  whatever  diathesis  (rheumatism,  syphilis)  may  be  taken  as 
giving  rise  to  the  condition. 

Arcus  Senilis. — This  is  a  change  which  is  developed  in  the 
cornea  without  previous  inflammation.  It  presents  the  appear- 
ance of  a  grayish  line  a  little  inside  the  margin  of  the  cornea 
and  all  round  it,  most  marked  above  and  below,  and  never 
advancing  further  toward  its  centre.  It  is  most  common  in 
elderly  people,  but  is  sometimes  seen  in  youth,  and  even  in 
childhood.  No  functional  changes  are  caused  by  it,  nor  does  it 
interfere  with  the  healing  of  a  wound  which  may  be  made  in 
that  part  of  the  cornea.  Arcus  senilis  is  caused  by  a  hyaline 
degeneration  of  the  corneal  cells  and  fibrillse,  and  is  not  a 
sclerosis,  as  is  stated  by  some  authors. 

*  A  von  Graefe's  Archiv,  vol.  xix,  p.  87. 


CHAPTER  IX. 
DISEASES  OP  THE  SCLEROTIC. 

Inflammation  of  the  sclerotic  is  not  a  common  disease, 
although  the  diagnosis  "scleritis"  is  often  made  by  inex- 
perienced persons,  every  "  redness  of  the  white  of  the  eye " 
being  taken  for  inflammation  of  the  sclerotic.  Beginners  are 
warned  against  this  error.  Iritis,  cyclitis,  and  conjunctivitis, 
as  well  as  scleritis,  cause  redness  of  the  white  of  the  eye. 

The  diagnosis  from  conjunctivitis  is  easily  made  by  ob- 
serving whether  the  conjunctival  vessels  can  be  moved  over 
the  afiected  part  or  not ;  while  in  iritis  and  cyclitis  the  ciliary 
injection  is  confined  to  the  part  immediately  surrounding  the 
cornea.  Moreover,  in  iritis  the  appearances  of  the  iris  itself 
are  conclusive ;  and  in  scleritis,  as  will  just  now  be  seen,  the 
appearances  are  characteristic. 

Scleritis  attacks  only  that  part  of  the  sclerotic  which  is 
anterior  to  the  equator  of  the  eyeball,  and  is  either  superficial 
or  deep.  The  superficial  form  is  known  as  episcleritis.  Yet 
it  is  not  always  possible  to  distinguish  between  these  two 
forms  in  a  given  case,  as  the  appearances  in  the  early  stages 
are  very  similar.  They  are  probably  only  diflferent  degrees 
of  the  same  disease.  But  the  necessity  of  admitting  the  exist- 
ence of  two  forms  depends  upon  the  different  course  they  each 
take ;  the  superficial  form  being  a  relatively  harmless  disease, 
while  the  deep  form  entails  serious  consequences. 

Episcleritis  appears  as  a  circumscribed,  purplish,  rather  than 
red,  spot,  close  to,  or  2  to  3  mm.  removed  from,  the  corneal 
margin.  It  is  often  unattended  by  pain,  unless  when  the  eye  is 
exposed  to  irritating  causes,  and  need  not  be  elevated  above  the 
level  of  the  sclerotic  ;  but,  in  severe  cases,  there  is   a   decided 

225 


226  DISEASES   OF   THE   EYE. 

node  at  the  affected  place,  with  pain,  more  or  less  pronounced 
and  increased  on  pressure.  All  the  symptoms  disappear  in  the 
course  of  a  few  weeks,  and  reappear  at  an  adjoining  place ;  and, 
in  this  way,  in  time,  the  whole  circumference  of  the  sclerotic 
will  have  been  attacked.  The  duration  of  the  affection  is 
usually  long;  and,  in  those  instances  where  the  entire  sclerotic 
becomes  affected  by  degrees,  the  process  may  last  for  years,  on 
and  off.  Both  eyes  are  often  affected.  The  disease  is  liable  to 
leave  behind  it  a  dusky  discoloration  of  the  sclerotic  where 
each  node  was  seated,  but  otherwise  no  harm  to  the  eye 
ensues.  But  the  patient  should  be  made  acquainted  with  the 
tedious  nature  of  the  affection.  Very  mild  attacks  of  epi- 
scleritis will  be  met  with,  which  pass  away  in  a  few  days,  and 
do  not  recur. 

Causes. — The  affection  is  often  of  rheumatic  origin  ;  it  occurs 
sometimes  in  persons  of  scrofulous  or  syphilitic  constitutions  ; 
and  it  is  more  frequent  in  senior  adults  than  in  children  or 
young  people,  and  more  commonly  attacks  women  than  men. 

Treatment. — No  irritant  should  be  applied  to  the  eye.  Local 
treatment  should  be  confined  to  warm  fomentations  and  protec- 
tion. In  addition  to  these,  massage  should  be  used,  if  there  be 
not  too  great  tenderness  on  pressure.  Leeching  at  the  external 
canthus  is  of  use  when  the  pain  is  severe.  As  regards  internal 
remedies,  where  a  syphilitic  taint  is  present,  mercury  should  be 
employed  ;  if  struma,  cod-liver  oil,  maltine,  etc. ;  or  if,  as  is 
most  frequently  the  case,  the  rheumatic  taint  be  the  source  of 
the  evil,  large  doses  of  salicylate  of  sodium,  say  20  grains,  four 
times  a  day,  will  often  be  found  to  act  well.  Iodide  of  potas- 
sium and  hypodermic  injections  of  pilocarpine  are  useful 
remedies  in  some  cases  of  this  obstinate  disease. 

Deep  Seleritis. — Here  the  whole  sclerotic  is  more  likely  to  be 
affected  at  once  than  in  the  milder  form  ;  although  cases  often 
enough  occur  where  only  an  isolated  node  is  present  at  a  time. 

It  is  the  progress  of  the  case  alone  which  can  render  the 
diagnosis  certain,  and  hence  the  importance  of  a  guarded  prog- 
nosis in  the  early  stages  of  every  case  of  seleritis.     In  the   deep 


DISEASES   OF   THE   SCLEROTIC.  227 

form,  changes — thinDing  and  softening — of  the  scleral  tissue 
take  place,  which  render  the  latter  less  resistant,  and,  conse- 
quently, expose  it  to  distention  by  even  the  normal  intraocular 
tension.  The  result  of  this  is  a  bulging  (staphyloma)  of  the 
anterior  part  of  the  eyeball.  This  bulging  in  itself  produces 
myopia,  and  has  a  deleterious  effect  upon  the  sight;  but,  at  a 
later  period,  vision  is  often  wholly  destroyed  by  secondary 
glaucoma.  It  may  happen  that  the  thinning,  etc.,  of  the  sclero- 
tic affects  only  a  portion,  and  not  the  whole,  of  its  anterior 
surface;  and,  in  such  a  case,  the  resulting  staphyloma  will  be 
confined  to  that  part  of  the  sclerotic.  A  staphyloma,  whether 
total  or  partial,  presents  a  bluish-gray  appearance,  due  to  the 
shining  through  the  thinned  sclerotic  of  the  uveal  tract. 

Either  with  or  without  such  staphylomatous  changes,  sclerotiz- 
ing  opacity  of  the  cornea  may  come  on,  and  iritis,  choroiditis, 
and  opacity  of  the  vitreous  humor  are  not  uncommon  complica- 
tions.    Both  eyes  are  usually  affected. 

Cause. — Young  adults  are  the  most  common  subjects  of  deep 
scleritis,  and  females  more  often  than  males.  Congenital  syphi- 
lis, rheumatism,  struma,  and  disturbances  of  menstruation  are 
the  most  common  assignable  causes. 

Treatment. — There  are  few  diseases  less  amenable  to  treat- 
ment. When  any  of  the  above  causes  can  be  assumed  to  be 
present,  the  suitable  remedies  are,  of  course,  indicated.  Besides 
this,  warm  fomentations,  dry  cupping  on  the  temple,  or  the  arti- 
ficial leech,  complete  rest  of  the  eyes,  and  protection  with  dark 
glasses  are  to  be  recommended. 

When  all  acute  inflammation  has  passed  away,  an  iridectomy 
is  sometimes  indicated — either  for  optical  purposes,  when  the 
pupil  is  obstructed  by  corneal  opacity,  or  for  the  purpose  of 
reducing  glaucomatous  tension. 

Injuries  of  the  Sclerotic. — Ruptures  and  perforating  wounds 
are  those  which  have  to  be  considered.  Mere  losses  of  substance 
may  be  said  not  to  occur. 

The  primary  danger  of  a  rupture  or  perforating  wound  of  the 
sclerotic — apart  from  the  loss  of  contents  of  the  eyeball,  which  is 


228  DISEASES   OF   THE   EYE. 

often  associated  with  it — consists  in  the  possibility  of  infecting 
organisnas  being  introduced  into  the  interior  of  the  eye,  and 
there  setting  up  serious  inflammatory  reaction. 

A  large  and  gaping  wound  is  easily  recognized.  A  portion  of 
the  choroid,  ciliary  body,  or  iris,  according  to  the  position  of  the 
wound,  probably  lies  in  it,  or  part  of  the  vitreous  humor  may  be 
found  in  it;  while  the  vitreous  humor,  as  seen  through  the  pupil, 
will  be  found  full  of  blood  (hsemophthalmos),  and  blood  may  be 
present  in  the  anterior  chamber  (hyphsema,  '3-o,  under)  al/aa, 
blood),  especially  if  the  wound  be  far  forward.  Small  wounds 
may  be  concealed  by  subconjunctival  hemorrhage,  and  here  re- 
duced tension  of  the  eyeball  is  sometimes  a  valuable  diagnostic 
sign. 

Clean-cut  perforating  wounds  of  the  sclerotic  often  heal  with- 
out inflammatory  reaction,  even  when  portions  of  the  uveal  tract, 
or  vitreous  humor,  are  prolapsed  into  it,  these  prolapsed  parts 
becoming  incarcerated  in  the  cicatrix.  Even  irregular  ruptures 
of  the  sclerotic  from  blows,  with  prolapse  of  uvea,  and  vitreous 
humor,  and,  as  sometimes  occurs,  evacuation  of  the  lens,  may 
heal  without  inflammatory  reaction.  It  may  here  be  mentioned 
that  these  ruptures  from  blows  almost  always  occur  close  to  the 
corneal  margin,  and  concentrically  with  it,  and  lie  usually  near 
its  upper,  or  upper  and  inner,  margin.  And  one  often  sees  the 
conjunctiva  remain  intact  over  the  rupture,  with  perhaps  the  lens 
dislocated  under  it. 

When  inflammatory  reaction  follows  upon  one  of  these  injuries, 
it  may  either  be  of  the  purulent  or  plastic  form.  In  the  former 
case  all  the  contents  of  the  eyeball  take  part  in  the  suppuration 
and  we  term  it  panophthalmitis  ;  phthisis  bulbi  being  its  ultimate 
result.  In  the  plastic  form  the  iris  and  ciliary  body  alone  are 
implicated,  and  sight  is  slowly  lost;  the  eye  here,  too,  becoming 
phthisical.  Of  the  two,  the  latter  process  is  the  more  serious,  as 
it  may  give  rise  to  sympathetic  ophthalmitis,  a  danger  which  is 
not  associated  with  the  eye  lost  through  panophthalmitis. 

Where  the  wound  has  been  produced  by  a  small  foreign  body, 
which  has  remained  in  the  interior  of  the  eye,  the  seriousness  of 


DISEASES   OF   THE   SCLEROTIC.  229 

the  position  is  much  aggravated  ;  but  the  discussion  of  this 
matter  will  be  treated  of  in  Chap.  XIV,  on  Diseases  of  the  Vit- 
reous Humor. 

Treatment. — In  cases  where  the  wound  is  small,  no  suture  need 
be  applied ;  a  bandage  will  be  sufficient  to  promote  the  natural 
tendency  to  healing.  But,  where  the  wound  is  large  and  gaping, 
any  prolapsed  choroid,  etc.,  should  be  first  freely  irrigated  with 
sublimate  lotion,  1  in  5000,  and  reduced  as  well  as  possible,  and 
then  the  margins  of  the  wound  drawn  together  by  a  few  points 
of  suture  in  the  sclerotic.  A  bandage  is  applied,  and  the  patient 
kept  quiet  in  bed.  But  if  the  injury  be  such — very  wide  wound, 
much  loss  of  contents  of  the  eyeball,  or  extensive  intraocular 
hemorrhage — as  to  render  restoration  of  useful  sight  beyond 
reasonable  hope,  it  will  be  wiser  to  remove  the  eyeball  at  once, 
rather  than  run  the  risk  of  sympathetic  ophthalmitis  without 
compensating  advantage. 

Tumors  of  the  Sclerotic  are  almost  unknown  as  primary 
growths,  but  fibroma,  sarcoma,  and  osteoma  have  been  so 
observed. 


CHAPTER  X. 

DISEASES  OP  THE  UVEAL  TRACT. 

(Iris,  Ciliary  Body,  and  Choroid). 

If  it  be  remembered  that  the  iris,  ciliary  body,  and  choroid 
closely  resemble  each  otherhistologically,  that  their  blood  supply 
is  identical,  and  that  they  form  with  each  other  a  continuous 
membrane,  it  is  a  matter  of  surprise  to  learn  that  any  one  of 
these  three  divisions  of  the  uveal  tract  can  undergo  inflamma- 
tion, while  the  other  two  remain  perfectly  healthy.  Yet  this  is, 
by  no  means  uncommonly,  the  case.  But  it  is,  perhaps,  more 
common  for  at  least  two  of  them,  and  especially  the  iris  and 
ciliary  body  {irido-cyclitis),  to  be  simultaneously  inflamed  ;  and 
the  entire  tract  may,  of  course,  be  affected  at  once.  Clinically 
we  cannot  always  know  whether  only  one,  or  more  than  one, 
division  of  the  uveal  tract  is  in  a  state  of  inflammation,  and 
this  uncertainty  of  diagnosis  is  particularly  liable  to  arise  when 
there  is  severe  acute  iritis,  for  then  the  symptoms  present  might 
all  be  derived  from  the  iritis  alone.  It  may  be  taken  for  granted 
that  in  every  rather  severe  case  of  iritis,  particularly  in  those  of 
syphilitic  origin,  more  or  less  cyclitis  is  also  present ;  while  a 
deep  anterior  chamber,  or  tenderness  on  pressure,  increases  the 
suspicion.  In  slight  cases  of  iritis  there  will,  probably,  be  no 
cyclitis. 

It  is  only  after  the  acute  inflammatory  symptoms  have  sub- 
sided, and  the  pupil  has  become  clear,  that  disseminated  changes 
in  the  choroid,  opacities  in  the  vitreous  humor,  and  even  retinitis 
and  optic  neuritis,  which  may  lead  to  optic  atrophy,  can  be  dis- 
covered, with  their  corresponding  depreciation  of  vision. 

It  is  desirable,  in  a  systematic  consideration  of  inflammation 
of  the  uveal  tract,  to  discuss  it  under  the  separate  headings  of 

230 


THE    IRIS.  231 

the  iris,  ciliary  body,  and  choroid  ;  and  the  same  remark  applies 
to  the  other  diseases  and  to  the  injuries  of  this  tunic. 

Iritis. 

The  most  rational  division  of  the  different  kinds  of  iritis  is 
that  founded  on  their  pathology,  namely  :— (1)  Simple  Plastic 
Iritis;  (2)  Serous  Iritis;  and  (3)  Parenchymatous  (including 
Purulent)  Iritis. 

Their  Common  Characteristics,  more  or  less  marked,  are : — 

Discoloration,  loss  of  lustre  and  of  distinctness  of  pattern,  and 
functional  disturbances  (impaired  mobility)  of  the  iris,  with 
contraction  of  the  pupil.  The  loss  of  lustre  and  of  distinctness 
of  pattern  is  due  to  an  alteration  in  the  endothelium,  which  covers 
the  surface  of  the  iris,  to  the  presence  of  lymph,  and  to 
cloudiness  of  the  aqueous  humor.  The  change  in  color  is  due  to 
hypersemia  of  the  iris,  as  well  as  to  the  presence  of  the  inflam- 
matory products;  a  blue  iris  becomes  greenish,  a  brown  iris 
yellowish.  The  impaired  mobility  and  the  contracted  pupil  are 
due  to  the  hypersemia,  to  spasm  of  the  sphincter  iridis,  and  to 
posterior  synechise. 

Exudation  of  inflammatory  products  is  present,  in  greater  or 
less  degree,  in  all  these  forms,  and  is  found  :  (1)  on  either  sur- 
face of  the  iris  and  in  the  pupil,  in  plastic  iritis ;  (2)  in  the 
aqueous  humor  and  posterior  surface  of  the  cornea,  in  serous 
iritis ;  (3)  in  the  tissue  of  the  iris,  in  parenchymatous  iritis. 

Posterior  synechise  (o-avc'/ccv,  to  hind  together),  i.  e.,  adhesions 
between  the  iris  and  the  anterior  capsule  of  the  lens,  occur  as 
the  result  of  inflammatory  exudation  on  the  posterior  surface  or 
on  the  pupillary  margin  of  the  iris.  The  presence  of  posterior 
synechise  is  ascertained  by  observing  the  motion  of  the  pupil 
when  the  eye  is  placed  alternately  in  strong  light  and  in  deep 
shadow,  or  by  observing  the  effect  of  a  drop  of  atropine  solu- 
tion on  the  pupil,  the  latter  dilating  only  at  those  places  where 
there  are  no  synechias.  If  the  entire  pupillary  margin  have  be- 
come adherent,  the  condition  is  termed  complete  posterior 
synechia,  circular  posterior  synechia,  ring  synechia,  or  "  exclu- 


232  DISEASES  OF   THE   EYE. 

sion  "  of  the  pupil ;  and  in  such  cases,  if  of  some  standing, 
atropine  has  no  effect  on  the  pupil.  If  the  area  of  the  pupil  be 
filled  with  exudation,  circular  synechias  being  usually  also 
present,  the  condition  is  known  as  "  occlusion  "  of  the  pupil. 
Total  posterior  synechia  is  the  condition  in  which  the  whole 
posterior  surface  of  the  iris  is  adherent  to  the  capsule  of  the  lens. 

In  addition  to  the  foregoing,  circurocorneal  injection  of  the 
ciliary  vessels  is  a  common  symptom  in  most  cases  of  iritis. 

The  subjective  symptoms  in  iritis  consist,  in  the  first  place, 
of  pain  due  to  irritation  of  the  ciliary  nerves  in  the  inflamed 
part.  Yet  this  pain  is  not  always  referred  to  the  eye  itself, 
but  often  appears  in  the  form  of  supra-orbital  neuralgia, 
or  affecting  the  infra-orbital  division  of  the  fifth  nerve. 
Dimness  of  vision  is  the  second  subjective  symptom  of  iritis. 
It  may  be  due  to  cloudiness  of  the  aqueous  humor  or  cornea, 
or  to  exudation  of  lymph  in  the  pupillary  area  on  the  anterior 
capsule  of  the  lens,  or,  where  the  ciliary  body  is  implicated, 
to  opacities  in  the  vitreous  humor. 

Cases  of  iritis  in  which  there  has  been  no  pain  and  no 
circumcorneal  injection,  and  in  which  the  failure  of  sight 
alone  it  is  which  brings  the  patient  to  the  surgeon,  are  not 
uncommon.  Examination  then  discovers  the  presence  of 
extensive  posterior  synechise,  which  have  probably  been 
gradually  forming  for  a  long  time  back.  These  cases  of  "  quiet 
iritis "  belong  to  the  plastic  form,  and  are,  in  my  experience, 
usually  due  to  rheumatism  {vide  infra). 

A  mistake  into  which  beginners  very  often  fall  is  to  take 
a  case  of  iritis  to  be  conjunctivitis  or  scleritis  (see  p.  84), 
the  "  redness  of  the  white  of  the  eye  "  being  what  misleads. 
The  condition  of  the  iris  itself  will  assist  most  in  the  diag- 
nosis. Moreover,  the  pain  in  iritis  is  of  neuralgic  character, 
but  in  conjunctivitis  is  similar  to  that  caused  by  a  foreign 
body  in  the  conjunctival  sac.  In  iritis  there  is  no  discharge, 
while  in  conjunctivitis  the  eyelids  are  gummed  in  the  morning 
by  muco-purulent  discharge.  Of  course,  iritis  and  conjunctivitis 
may  occur  together. 


THE   IRIS.  233 

Simple  Plastic  Iritis  is  the  most  common  form.  In  it 
the  circumcorneal  injection  is  generally  well  marked,  some- 
times causing  elevation  of  the  limbus  of  the  conjunctiva,  and 
even  general,  although  slight,  chemosis.  In  very  mild  cases, 
however,  as  also  in  chronic  cases,  the  injection  may  be  slight. 
The  loss  of  lustre  and  of  distinctness  of  pattern  of  the  iris  is 
well  marked,  and  there  is  considerable  change  in  the  color 
of  the  iris. 

Posterior  synechise  are  very  apt  to  form.  In  some  rare 
cases  of  plastic  iritis,  an  enormous  quantity  of  gelatinous  exuda- 
tion is  present  in  the  anterior  chamber. 

In  Secondary  Syphilis  one  often  sees  iritis,  which,  although 
doubtless  due  to  the  syphilitic  taint,  presents  no  clinical 
characteristic  different  from  ordinary  simple  plastic  iritis,  yet  it 
is  probable  that  many  of  these  cases  are  parenchymatous,  or 
coudylomatous. 

Rheumatic  Iritis  is  of  the  simple  plastic  form,  but  accom- 
panied by  circumcorneal  injection,  which  is  great  in  proportion 
to  the  other  signs  of  iritis  present.  The  pain  in  rheumatic 
iritis  is  often  peculiarly  severe.  Yet,  as  I  have  already  stated, 
**  quiet  iritis"  is  most  often  due  to  rheumatism. 

Gonorrhoeal  Iritis  is  a  mixture  of  the  plastic  and  serous 
forms.  It  does  not  attend  on,  nor  immediately  follow,  a  gonor- 
rhcea ;  but  an  attack  of  rheumatic  arthritis,  usually  of  the  knees, 
always  intervenes.     Gonorrhoeal  iritis  is  extremely  rare. 

Serous  Iritis.  (Keratitis  punctata.  Aquocapsulitis  Des- 
cemetitis.) — Here  the  exudation  is  mainly  a  serous  fluid.  From 
this  fluid  fibrinous  elements,  in  the  form  of  very  fine  yellowish 
spots,  are  precipitated  on  the  posterior  surface  of  the  cornea, 
chiefly  in  its  lower  quadrant,  and  often  in  a  triangular  shape, 
the  base  of  the  triangle  corresponding  with  the  lower  margin 
of  the  cornea,  the  apex  being  directed  toward  the  centre  of 
the  cornea,  and  the  finer  dots  near  the  apex.  The  triangular 
shape  is  a  mechanical  result  of  the  motions  of  the  eyeball. 

In  cases  where  the  corneal  deposit  continues  for  a  length 
of  time,  owing  to  degeneration  of  the  posterior  epithelium, 
20 


234  DISEASES   OF   THE   EYE. 

permanent  secondary  changes  in  the  true  cornea  are  pro- 
duced, and  a  consequent  peculiar  triangular  opacity  at  the 
lower  part  of  the  cornea  will  ever  afterward  indicate  the 
nature  of  the  process  which  has  gone  before. 

In  serous  iritis  the  pupil  is  usually  not  contracted,  and 
the  circumcorneal  injection  is  slight. 

The  anterior  chamber  is  often  deep,  owing  to  the  quantity 
of  fluid  secreted,  and  the  aqueous  humor  is  cloudy.  The 
increase  in  the  contents  of  the  anterior  chamber  frequently 
causes  increase  in  the  intraocular  tension.  Pure  serous  iritis 
is  perhaps  not  so  common  as  a  mixed  form  of  seroplastic  iritis. 

But  there  is  good  reason  to  regard  all  these  cases  of  keratitis 
punctata  as  due,  not  to  inflammation  of  the  iris,  but  to  cyclitis. 

Parenchymatous  (including  Purulent)  Iritis. — Here  the  in- 
flammatory product  is  situated  in  the  tissue  of  the  iris.  The 
consequent  swelling  of  the  iris  may  be  present  over  its  whole 
extent,  or  may  be  confined  to  a  circumscribed  part  of  it. 
In  the  latter  case  the  swelling  is  sometimes  called  a  condy- 
loma. The  color  of  the  iris  changes  remarkably,  at  the 
affected  part,  to  a  yellowish  or  reddish-yellow  hue,  and  new 
vessels  are  formed  in  it. 

In  Syphilis,  late  in  the  secondary  stage,  a  form  of  iritis  occurs 
which  may  always  be  recognized  as  syphilitic.  It  is  character- 
ized by  the  formation  of  circumscribed  tumors,  or  small  condy- 
lomata of  a  pale  yellowish  color,  the  rest  of  the  iris  being, 
apparently,  intact.  These  tumors  vary  in  size  from  that 
of  a  hemp-seed  to  that  of  a  small  pea,  and  are  situated 
usually  at  the  pupillary  margin,  occasionally  at  the  periphery 
of  the  iris,  and  very  rarely  in  the  body  of  the  iris.  There 
may  be  but  one  tumor  present,  and  there  are  seldom  more  than 
three  or  four.  This  form  belongs  to  the  parenchymatous  class, 
and  is  by  no  means  common.  Yet  many  authors  hold  that 
in  most,  if  not  all,  cases  of  syphilitic  iritis,  condylomatous 
tumors  are  present,  but  of  such  small  size  as  to  escape 
detection  with  our  ordinary  clinical  methods. 

Symptoms  of  Iritis  in  General. — 1.  Pain.     This  is  situated  not 


THE    IRIS.  235 

SO  much  in  the  eye  as  in  the  brow  over  it,  in  the  corresponding 
side  of  the  nose,  and  in  the  malar  bone,  and  may  even  extend 
to  the  whole  side  of  the  head.  It  varies  in  its  intensity; 
it  is  usually  more  severe  at  night,  and  is  often  called  neu- 
ralgia by  the  patients.  The  simple  plastic  form  is  the  one 
attended  by  the  most  severe  pain,  the  serous  form  is  gener- 
ally unattended  by  pain,  while  the  parenchymatous  form  is 
often  excessively  painful,  and  again  completely  painless.  2. 
Lachrymation  and  photophobia  are  occasionally  present,  but 
never  to  such  a  degree  as  is  often  observed  in  certain  corneal 
affections.  3.  Dimness  of  vision.  This  is  usually  complained 
of  as  soon  as  the  inflammation  is  pronounced.  Cloudiness 
of  the  aqueous  humor  and  keratitis  punctata  affect  sight  in 
proportion  to  their  degree,  and  exudation  in  the  pupil  may 
reduce  vision  to  a  quantitative  amount. 

The  tension  of  the  eye  in  iritis  is  usually  normal,  but  in 
some  cases  of  violent  plastic,  serous,  and  parenchymatous  iritis 
the  tension  will  be  found  high. 

Prognosis. — The  length  of  duration  of  an  attack  of  iritis 
cannot  be  foretold  at  the  outset.  Cases  which  are,  in  other 
respects,  mild,  i.e.,  where  the  pupil  dilates  well  and  rapidly 
to  atropine,  where  the  aqueous  humor  is  clear,  and  where 
but  little  lymph  is  thrown  out,  often  continue  for  weeks 
irritable  and  painful,  with  a  marked  tendency  to  relapse  if 
treatment  be  at  all  relaxed.  An  attack  of  iritis  may  last  from 
two  to  eight  weeks,  the  plastic  form  being  the  most  rapid 
and  the  serous  form  the  slowest.  Recurrences  of  the  inflam- 
mation are  common,  owing  to  continuance  of  the  constitu- 
tional taint  which  gave  rise  to  the  iritis  in  the  first  instance. 

It  is  possible  that  an  attack  of  any  form  of  iritis,  if  carefully 
treated  from  the  beginning,  may  leave  the  eye  in  as  healthy  a 
condition  as  before ;  but  it  is  quite  as  common,  in  spite  of  every 
effort,  to  find  posterior  synechise,  isolated  or  as  a  circular  syne- 
chia, left  behind.  The  presence  of  a  few  isolated  synechise,  if 
the  pupil  be  clear,  is  in  itself  harmless  to  sight,  but,  if  relapses 
take  place  and  fresh  adhesions  be  formed,  a  complete  posterior 


236  DISEASES   OF  THE   EYE. 

synechia  may  ultimately  be  established.  When  this  occurs,  the 
aqueous  humor  being  still  secreted  behind  the  iris,  the  latter 
becomes  bulged  forward,  like  the  sail  of  a  ship,  until  it 
touches  the  peripheral  part  of  the  cornea,  while  the  centre  of 
the  anterior  chamber  retains  its  normal  depth.  This  condition 
is  very  liable  to  induce  glaucomatous  tension  (secondary  glau- 
coma) and  consequent  loss  of  vision ;  or,  if  the  eye  escape  this 
danger,  the  traction  on  the  ciliary  body  produced  by  the  tensely 
stretched  iris  may  develop  chronic  inflammation  of  the  ciliary 
body  and  choroid — so-called  chronic  irido-cyclitis,  or  irido-cho- 
roiditis ;  and  this  may  lead  to  diminished  tension  and  phthisis 
bulbi,  with  detachment  of  the  retina  and  calcification  of  the  lens. 
Or,  the  eye  having  been  first  blinded  by  high  tension,  may  at  a 
later  period  undergo  phthisis  bulbi. 

Complete  posterior  synechia  may  of  course  result  from  the 
first  and  only  attack  of  iritis,  and  not  by  means  of  repeated 
relapses. 

In  some  cases  of  plastic  or  seroplastic  iritis,  the  vitreous 
humor  becomes  more  or  less  opaque,  and  this  condition  does  not 
always  disappear  as  the  iritis  gets  well.  Or,  it  may  not  be  pos- 
sible to  ascertain  its  presence  until  after  the  inflammatory  process 
in  the  iris  has  subsided.  Very  great  and  permanent  deteriora- 
tion of  vision  may  result  in  such  instances,  and  they  emphasize 
the  importance  of  a  cautious  prognosis  at  the  commencement. 
There  can  be  no  doubt  but  that  in  these  cases  the  ciliary  body 
is  inflamed  along  with  the  iris,  although  the  fact  cannot  be 
directly  ascertained. 

Causes. — Iritis  is  not  common  in  children,  except  as  complica- 
ting a  corneal  process  or  as  a  result  of  congenital  syphilis. 
Toward  puberty  slight  plastic  iritis  is  sometimes  found  in  girls. 
Youth  and  middle  age  are  the  times  of  life  in  which  iritis  is 
most  often  seen,  while  in  old  age  it  again  becomes  rare. 

More  than  fifty  per  cent,  of  the  cases  depend  on  syphilis,  and 
a  large  proportion  of  the  remainder  are  due  to  rheumatism. 
During  desquamation  after  smallpox  plastic  iritis  is  some- 
times   observed.     In    metria    and    septicaemia    purulent    iritis 


THE    IRIS.  237 

occurs,  as  also  with  typhoid  fever,  pneumonia,  and  recurrent 
fever.  Diabetes  sometimes  causes  iritis  of  a  plastic  or  puru- 
lent form. 

Treatment. — Atropine  is,  above  every  other,  the  most  impor- 
tant means.  It  is  most  commonly  used  in  solution  (Atrop.  sulph. 
gr.  iv,  Aq.  dest.  sj)  as  drops ;  but  an  atom  of  sulphate  of  atro- 
pine in  substance,  placed  in  the  conjunctival  sac,  gives  a  very 
active  reaction,  and  I  prefer  its  use  in  one  or  other  of  these 
forms.  It  is  also  used  in  the  form  of  an  ointment  (Atrop.  sulph. 
gr.  iv,  vaselin  $j),  and  gelatine  discs  containing  atropine  are 
manufactured.  By  paralyzing  the  sphincter  iridis,  atropine 
provides  rest  for  the  inflamed  iris,  and  if  adhesions  have 
already  formed  the  dilatation  of  the  pupil  may  break  them 
down,  while  if  none  are  yet  present  the  dilatation  will 
greatly  aid  in  preventing  their  formation.  To  produce  a  max- 
imum effect,  where  it  is  desired  to  break  down  adhesions,  six 
drops  should  be  instilled  into  the  eye,  with  an  interval 
of  from  five  to  ten  minutes  between  each  ;  and,  in  this  way, 
every  drop  has  time  to  make  its  way  into  the  anterior  chamber, 
and  finally  the  accumulated  effect  of  all  six  is  obtained.  More 
than  one  drop  can  hardly  be  retained  in  the  conjunctival  sac  at 
a  time.  The  usual  run  of  cases  of  iritis  require  a  drop  in  the 
eye  from  twice  to  four  times  a  day. 

Some  individuals  are  peculiarly  susceptible  of  Atropine 
Poisoning,  of  which  the  symptoms  are :  Dryness  of  the  throat, 
fever,  fullness  in  the  head,  headache,  delirium,  coma.  The 
antidote  is  morphia,  of  which  i  grain  used  hypodermically 
neutralizes  -^-^  grain  of  atropine  in  the  system.  Atropine 
poisoning  occurs  by  reason  of  introduction  of  the  solution  into 
the  stomach  through  the  lachrymal  canaliculi  and  the  nose 
and  fauces,  and  in  order  to  prevent  this  the  finger  (of  the 
patient)  may  be  placed  in  the  inner  canthus,  so  as  to  occlude 
both  canaliculi  during,  and  for  some  moments  after,  the  in- 
troduction of  the  drop  into  the  eye.  After  long  use  of  atro- 
pine, the  skin  of  the  lower  eyelid,  or  of  both  eyelids,  from 
infiltration    with    the    drug,    often    becomes    eczematous,   red, 


238  DISEASES   OF   THE   EYE. 

swollen,  and  painful ;  and  in  other  cases  follicular  conjunc- 
tivitis is  induced.  If  these  occur,  sol.  extr.  belladonnse 
(gr.  viij  ad  ,^j)  should  be  substituted  for  atropine,  and  suit- 
able remedies  (see  pp.  87  and  132)  used  for  skin  or  con- 
junctiva. In  old  people,  tenesmus  and  retention  of  urine 
sometimes  result  from  use  of  atropine. 

Atropine,  while  it  is  so  useful  a  means  in  the  treatment  of 
inflammations  of  the  iris,  ciliary  body,  and  cornea,  is  of  no 
benefit  in  many  other  diseases  of  the  eye,  and  is  positively 
harmful  in  some  of  them.  It  is  necessary  to  make  this  state- 
ment very  explictly,  for  some,  perhaps  I  should  say  many, 
medical  men,  who  have  not  devoted  attention  to  the  subject 
of  eye  disease,  habitually  include  atropine  in  every  eye-water 
they  prescribe.  If  the  disease  prescribed  for  be  conjunctivitis, 
as  it  very  often  is,  the  atropine  is  calculated  rather  to  increase 
than  to  relieve  the  conjunctival  affection ;  while,  if  the  patient 
be  advanced  in  life,  there  is  always  the  danger  that  a  tendency 
to  glaucoma  may  be  present,  and,  in  such  a  case,  the  dilatation 
of  the  pupil  caused  by  the  atropine  will  be  sufficient  to  bring 
on  an  attack  of  acute  glaucoma.  In  these  days,  it  falls  to  the 
lot  of  most  ophthalmic  surgeons  to  be  called,  at  one  time 
or  another,  to  a  case  of  acute  glaucoma,  brought  on  by  the 
gratuitous  use  of  atropine  in  this  manner.  It  is  to  be  feared 
that  the  reason  for  this  random  prescribing  of  atropine  is 
to  be  found  in  an  ignorance  of  diagnosis,  which  leads  prac- 
titioners to  throw  atropine  with  a  number  of  other  drugs  into 
their  eye-waters,  in  the  hope  that  some  of  the  ammunition 
will  hit  the  mark,  wherever  the  latter  may  be. 

Dark  protection  spectacles  should  be  worn  by  patients 
suffering  from  iritis ;  and,  in  severe  cases,  they  should  be  con- 
fined to  a  dark  room,  and  even  to  bed. 

In  Simple  Plastic  Iritis,  iodide  of  potassium  or  perchloride 
of  mercury  may  be  given  internally.  If  there  be  much  irrita- 
tion, pericorneal  injection,  or  chemosis,  leeching  at  the  ex- 
ternal canthus  is  of  use.  Intermittent  warm  fomentations 
(every   two  hours)   promote   healthy  vascular   reaction.      Pain 


THE   IRIS.  239 

is  to  be  relieved  by  hypodermic  injections  of  morphia  and  by 
chloral  internally. 

In  the  rheumatic  iritis,  and  in  iritis  due  to  diabetes,  salicylate 
of  sodium  in  large  doses  (20  to  30  grains  every  three  hours) 
has  often  a  remarkably  favorable  effect. 

In  Serous  Iritis,  a  small  quantity  of  atropine  will  suffice, 
as  there  is  little  tendency  to  the  formation  of  synechise ;  and 
the  irritation  being  slight,  leeching  is  unnecessary.  The  skin 
(pilocarpine  hypodermically,  Turkish  baths,  and  dry  rubbing), 
kidneys,  and  bowels  should  be  acted  on ;  and  to  the  diuretics 
prescribed  some  iodide  of  potassium  may  be  added.  Turpentine 
in  5j  doses,  as  recommended  by  Carmichael,  of  Dublin,  is  often 
a  useful  remedy  here.  Mr.  John  Tweedy  prefers  Chian  turpen- 
tine in  5-grain  doses  every  three,  four,  or  six  hours. 

Blistering  on  the  temples,  or  behind  the  ears,  is  with  many 
surgeons  a  favorite  remedy.  It  adds  to  the  annoyance  of 
the  patient,  but  I  have  no  belief  in  it  as  a  remedy  in  this, 
or,  indeed,  in  any  other  eye  disease. 

Great  care  is  required  in  watching  the  tension  of  the  eye 
in  this  form  of  iritis,  and,  if  it  be  found  to  increase  and  to 
remain  high  for  three  or  four  days,  paracentesis  of  the 
anterior  chamber  must  be  performed  to  reduce  it  temporarily 
while  the  iritis  is  still  progressing  toward  cure.  This  little 
operation  will  also  be  called  for  if  there  be  much  deposit  on 
the  posterior  surface  of  the  cornea,  as  by  means  of  it  the 
deposit,  to  a  great  extent,  may  be  floated  away.  (For  mode  of 
performing  paracentesis  see  p.  191.) 

In  Parenchymatous  Iritis  it  is  important  to  obtain  rapid 
absorption  of  the  inflammatory  products,  which  are  so  abun- 
dantly thrown  out,  and  which,  in  an  organ  like  the  eye,  would 
soon  cause  extensive  destruction.  Consequently,  unless  it  be 
the  purulent  form,  the  system  should  be  put  under  the  influence 
of  mercury  as  quickly  as  possible  by  the  use  of  inunctions  of 
mercurial  ointment,  or  by  small  doses  of  calomel  internally ;  and 
this  treatment  is  indicated  even  when  the  inflammation  is  not  of 


240  DISEASES   OF   THE   EYE. 

syphilitic   origin.     Warm   fomentations    are  useful.     An  after- 
treatment  with  iodide  of  potassium  is  to  be  employed. 

In  syphilitic  iritis  of  the  plastic  form  von  Graefe  was  fond  of 
the  following  formula: — 

R.  Hydrarg.  biniodid.jgr.  vj  ;  Potass,  iodidi,  5 iss  ;  Aq.  destill.,  ^ss  ; 
Syr.  aurant.,  51188.  M.  A  teaspoonful  to  be  taken  once  a  day.  The 
dose  to  be  gradually  increased. 

In  Purulent  Iritis,  quinine  and  salicylate  of  sodium  are  the 
most  suitable  internal  remedies. 

Injuries  of  the  Iris. 

Punctured  Wounds  of  the  eye  frequently  implicate  the  iris, 
but  rarely  do  so  without  also  injuring  the  crystalline  lens  or 
ciliary  body,  on  which  then  the  chief  interest  centres,  as  being 
the  organs  from  which  serious  reaction  is  apt  to  emanate.  If  a 
simple  incised  wound  of  the  iris  be  observed,  it  may  be  regarded 
as  of  little  importance,  for  inflammatory  reaction  need  not  be 
feared,  and  any  extravasation  of  blood  into  the  anterior  cham- 
ber (hyphsema)  becomes  absorbed,  while,  as  a  whole,  the  func- 
tions of  the  iris  will  probably  not  be  affected. 

Foreign  bodies  of  small  size,  such  as  bits  of  steel  or  iron,  may 
perforate  the  cornea  and  fasten  in  the  iris,  the  puncture  in  the 
cornea  closing  rapidly,  and  possibly  no  aqueous  humor  being 
lost.  It  is  necessary  always  to  remove  such  a  foreign  body 
without  delay,  although  for  some  time  it  may  cause  no  reaction. 
An  incision  should  be  made  with  a  Graefe's  knife  at  the  margin 
of  the  cornea  corresponding  to  the  position  of  the  foreign  body, 
and  the  portion  of  iris  containing  the  foreign  body  is  then  re- 
moved with  forceps  and  scissors. 

Blows  on  the  Eye  are  apt  to  cause  one  of  several  remarkable 
lesions  of  the  iris,  namely : — 

1.  Iridodialysis  (J'pt?,  dtdXu(Ti<^,  a  separating),  i.  e.,  separation  of 
the  iris  from  its  attachment  to  the  ciliary  body,  which  is  usually 
accompanied  by  considerable  hyphaema.     As  much  as  one-half 


THE    IRIS. 


241 


of  the  circumference  of  the  iris  may  be  involved  in  the  lesion  (Fig. 

92),  or  the  latter  may  be  so  small 

as  to   be  detected   only  by  aid   of 

light  transmitted  to  the  eye  by  the 

ophthalmoscope ;     and     then     not 

only  the    physiological    pupil,   but 

also  the  minute  marginal  traumatic 

pupil,    will    be  illuminated.      The 

functions    of   the    eye    after    such 

injury,  even  when  extensive,  may 

be  but  little  disturbed,  or  there  may  be  monocular  diplopia. 

Restoration  to  the  normal  state  in  these  cases  rarely  takes 
place.  I  have  observed  one  case  in  which  the  iridodialysis,  a 
very  minute  one,  was  healed,  and  there  is  one  other  such  case 
recorded.  The  lengthened  use  of  atropine  is  the  most  likely  way 
to  promote  such  a  result,  which  can  only  be  hoped  for  if  the 
iridodialysis  be  not  extensive,  and  the  case  be  seen  early. 

2.  Retroflexion  of  the  Iris. — :A  portion  of  the  iris  in  its  entire 
width  becomes  folded  back  on  the  ciliary  processes,  giving  the 
appearance  of  a  coloboma  produced  by  a  wide  and  peripheral 
iridectomy.  In  a  true  coloboma  the  ciliary  processes  would  be 
easily  seen,  but  not  so  in  retroflexion,  for  the  processes,  being 
covered  by  the  retroflected  iris,  present  a  smooth  surface.  A 
slight  dislocation  of  the  lens  in  the  direction  away  from  the  iris 
lesion  is  often  observed.  Retroflexion  of  the  iris  cannot  be 
cured. 

3.  Rupture  of  the  Sj^hincter  Iridis. — There  are  not  many  cases 
of  this  lesion  recorded;  although,  according  to  Hirschberg,"^  in 
all  cases  of  permanent  traumatic  mydriasis  the  margin  of  the 
pupil  is  torn.  My  observations  do  not  agree  with  this  view  of 
Hirschberg's,  nor  do  I  agree  with  him  in  thinking,  as  he  seems 
to  do,  that  rupture  of  the  sphincter  would  be  sufficient  to 
account  for  traumatic  mydriasis.  This  condition  is  also  in- 
curable. 


^  Centralbl.f.  Augenheilk.,  1886,  p.  368. 


21 


242  DISEASES    OF    THE    EYE. 

4.  Traumatic  Aniridia. — The  whole  iris  may  be  torn  from  its 
ciliary  insertion  and  found  lying  in  the  anterior  chamber,  or 
under  the  conjunctiva,  having  in  the  latter  case  passed  through 
a  rent  at  the  corneo-scleral  margin. 

5.  Anteversion. — This  must  always  be  accompanied  with  irido- 
dialysis.  The  detached  portion  of  iris  is  then  twisted  on  itself, 
so  that  the  uveal  surface  is  turned  to  the  front.* 

6.  Traumatic  Mydriasis. — Permanent  dilatation  of  the  pupil 
after  a  blow  is  not  very  uncommon,  and  is  commonly  referred 
to  paralysis  of  the  sphincter,  the  result  of  concussion  of  the 
delicate  nerve  endings  in  the  sphincter  itself.  (See  above, 
under  Rupture  of  the  Sphincter  Iridis.) 

New  Growths  of  the  Iris. 

Cysts. — These  vary  from  a  very  small  size  to  that  which  would 
fill  the  anterior  chamber.  They  may  have  either  serous  or  solid 
contents.  The  serous  kind  was  said  to  result  always  from  a 
trauma  causing  an  anterior  synechia,  or  otherwise  shutting  off  a 
fold  of  the  iris,  which  became  distended  into  a  cyst  by  accumu- 
lation of  aqueous  humor.  A  case,  however,  which  was  not  pre- 
ceded by  a  trauma  has  come  under  my  notice.  The  cysts  with 
solid  contents  (epidermoid  elements)  are  believed  to  have  their 
origin  in  an  eyelash  or  morsel  of  epidermis,  which  may  have 
made  its  way  into  the  anterior  chamber  by  occasion  of  a  perfor- 
ating corneal  wound.  All  these  cysts  are  sources  of  serious 
danger  to  the  eye  (irido-choroiditis,  glaucoma,  etc.),  and,  it  is 
stated,  may  even  be  the  cause  of  sympathetic  ophthalmitis,  and 
hence  their  removal  is  called  for.  This  can  be  effected  without 
much  difficulty  if  the  tumor  be  small,  but  if  it  have  attained  a 
large  size  the  attempt  may  be  unsuccessful.  A  long  incision 
should  be  made  in  the  corneo-scleral  margin,  and  the  cyst, 
along  with  the  portion  of  iris  to  which  it  is  attached,  drawn  out 
and  cut  off. 

Granuloma  is  the  name  given  to  a  benign  neoplasm  of  the  iris, 


*  L.  Werner,  in  Ophth.  Rev.,  1887,  p.  104. 


THE    IRIS.  243 

of  which  the  structure  resembles  granulation  tissue.  Clinically 
it  is  a  small,  pale  tumor,  or  there  niay  be  several  such  tumors, 
which  gradually  grow  to  fill  the  anterior  chamber,  rupture  the 
cornea,  and  finally  induce  phthisis  bulbi.  It  is  held  by  some 
that  these  growths  depend  on  a  syphilitic  taint,  and  by  others 
that  they  are  tuberculous. 

Tubercle. — This  appears  as  small  white  tumors,  from  the  size 
of  a  pin's  head  to  that  of  a  pea  and  larger.  Microscopically 
they  contain  small,  round  cells,  and  the  characteristic  giant  cells. 
By  early  removal  of  the  eye  oue  may  hope  to  avert  general 
tuberculosis,  as  a  case  of  Deutschmann's"^  shows. 

Primary  Sarcoma  (or  Melano- Sarcoma)  is  a  rare  disease  of 
the  iris.  When  the  tumor  is  very  small  it  may  be  removed  by 
an  iridectomy,  and  in  this  way  an  attempt  made  to  preserve  the 
eye ;  but  when  it  has  attained  any  size,  the  whole  eyeball  must 
be  removed. 

Congenital  Malformations  of  the  Iris. 

Heterophthalmos  (iz^pn^  different,  ocfda/./jjj^). — This  term 
indicates  that  the  color  of  the  iris  in  one  eye  is  different  from 
that  in  the  other. 

Corectopia  (y-oprt^  the  j^ujnl;  exzo-o'^,  out  of  position),  or  mal- 
position of  the  pupil.  The  pupil  sometimes  occupies  a  position 
further  from  the  centre  of  the  iris  than  normally. 

Polycoria  (-uXu?,  many;  xopy],  the  pupil). — Where  there  is 
more  than  one  pupil.  The  supernumerary  pupil  may  be 
separated  by  only  a  small  bridge  from  the  normal  pupil,  or  it 
may  be  situated  very  near  the  periphery  of  the  iris.  In  neither 
case  has  it  a  special  sphincter. 

Persistent  Pupillary  Membrane  appears  in  the  form  of  very 
fine  threads  stretched  across  the  pupil ;  and  these  diflTer  from 
posterior  synechise  in  being  attached  to  the  anterior  surface  of 
the  iris  some  distance  from  the  margin  of  the  pupil.  They  do 
not  interfere  with  the  motions  of  the  pupil  nor  with  vision. 

*  Graefe's  Archiv,  xxvii,  pt.  1,  p.  317. 


244  DISEASES   OF   THE    EYE. 

Coloboma    {■/.<>h>t36i,  maimed). — This   is   a  cleft    in    the    iris 


Fig.  93. 


Fin.  94. 


Fig  95. 

n 


Fig.  96. 


caused  by  an  arrest   of    development   (incomplete   closure   of 


THE   IRIS. 


245 


the  choroidal  fissure).  It  is  situated  almost  always  in  the  lower 
inner  quadrant,  at  a  position  corresponding  to  the  choroidal 
fissure  in  the  foetus,  and  it  varies  much  in  size  in  different 
cases.  It  is  sometimes  continued  into  the  ciliary  body  and 
choroid,  and  may  be  present  in  both  eyes,  and  a  notch  at  a 
corresponding  situation  in  the  crystalline  lens  is  not  uncom- 
mon. When  uncomplicated,  it  causes  little  or  no  defect  in 
vision. 

Irideremia  (.'V>.'c,  ipr^pla^  wcnit  of). — This  may  be  complete 
or  partial.  In  the  latter  case  it  may  be  the  inner  circle  which 
is  wanting,  giving  the  pupil  the  appearance  of  dilatation 
with  atropine.  Where  the  entire  iris  is  absent,  the  ciliary 
processes  can  be  seen  all  round.     The  condition  may  be  double- 

FiG.  97. 


sided.  The  patients  suffer  chiefly  from  dazzling  by  light, 
for  which  either  protection  or  stenopaeic  spectacles  are  to  be 
prescribed. 

Operations  on  the  Iris. 

Iridectomy. — This  is  performed  for  optical  purposes,  as  in 
zonular  cataract,  corneal  opacities,  or  closed  pupil ;  for  anti- 
phlogistic purposes,  as  in  recurrent  iritis,  etc. ;  and  to  reduce 
abnormally  high  intraocular  tension  in  primary  and  secondary 
glaucoma. 

The  instruments  required  are  :  A  spring  speculum,  a  fixation 
forceps  with  spring  catch  (Fig.  97),  a  lance-shaped  iridectomy 
knife  (Keratome)  (Fig.  93),  or  a  Graefe's  cataract  knife,  a  bent 
iris  forceps  (Fig.  94),  or  a  Tyrrell's  hook  (Fig.  95),  an  iris 
scissors  curved  on  the  flat  (Fig.  96),  and  a  small  spatula. 

The  width  of  the  coloboma  depends  a  good  deal  on  the  length 


246  DISEASES   OF    THE    EYE. 

of  the  corneal  incision,  for  it  cannot  be  wider  than  the  incision 
is  long.  Its  depth  depends  on  the  proximity  of  this  incision  to 
the  corneo-scleral  margin.  If  a  wide  and  very  peripheral  colo- 
boma  be  desired,  the  incision  must  be  long,  and  must  lie  actually 
in  the  corneo-scleral  margin  ;  the  iris  forceps  being  then  intro- 
duced, a  portion  of  the  iris  corresponding  to  the  length  of  the 
incision  may  be  seized  and  cut  off,  and  a  coloboma,  as  at  Fig. 
98,  produced.  Somewhat  inside  the  corneal  margin  will  give  a 
pupil  as  in  Fig.  99.  A  narrow  coloboma  (Fig.  100)  is  ob- 
tained by  a  short  corneal  incision,  which  may  be  more  or  less 
peripheral  as  circumstances  require,  and  by  using  a  Tyrrell's 
hook,  instead  of  an  iris  forceps,  for  catching  and  drawing  out 
the  iris. 

In  glaucoma,  a  wide  and  very  peripheral  coloboma  is  required. 

Fig.  98.  Fig.  99.  Fig.  100. 


For  antiphlogistic  purposes,  a  wide  iridectomy  is  also  necessary. 
But  for  optical  purposes,  a  narrow  iridectomy  is  required  ;  be- 
cause, with  a  wide  coloboma,  the  diffusion  of  light  may  be  very 
troublesome  to  the  patient. 

The  best  position  for  an  iridectomy  for  glaucoma,  or  for  anti- 
phlogistic purposes,  is  the  upper  quadrant  of  the  iris,  as  there 
the  subsequent  dazzling  by  light  and  the  disfigurement  are  least. 
But  the  position,  by  preference,  for  an  optical  pupil  is  below 
and  to  the  inside,  being  that  most  nearly  in  the  direction  of  the 
axis  of  vision.  If,  however,  this  position  be  occupied  by  a 
corneal  opacity,  the  coloboma  should  be  made  directly  down- 
ward, or  if  that  place  be  ineligible,  then  downward  and  out- 
ward, or  directly  downward,  or  directly  inward.  The  upward 
positions  are  not  satisfactory  for  optical  pupils,  owing  to  the 
over-hanging  of  the  upper  lid  ;  but  yet  it  often  happens  that  we 
have  no  other  choice. 


THE    CILIARY    BODY.  247 

III  the  Performance  of  an  Iridectomy  the  eye  should  be  fixed 
with  a  forceps  at  a  position  on  the  same  meridian  as  that  in 
which  the  coloboma  is  to  lie,  but  at  the  opposite  side  of  the  cor- 
nea and  close  to  the  latter.  The  point  of  the  lance-shaped  knife 
is  then  to  be  entered  almost  perpendicularly  to  the  surface  of  the 
cornea,  and  made  to  penetrate  the  latter.  The  handle  of  the  • 
knife  is  then  at  once  lowered,  and  the  blade  passed  on  into  the 
anterior  chamber  in  a  plane  parallel  to  the  surface  of  the  iris, 
until  the  incision  has  attained  the  required  length.  The  handle 
of  the  knife  is  now  lowered  still  more,  so  as  to  bring  the  point 
of  the  blade  almost  in  contact  with  the  posterior  surface  of  the 
cornea,  in  order  to  prevent  any  injury  to  the  lens  in  the  next 
motion.  The  knife  is  then  very  slowly  withdrawn  from  the  an- 
terior chamber.  At  the  same  time  the  aqueous  humor  flows  off 
and  the  crystalline  lens  and  iris  come  forward.  The  fixation- 
forceps  is  now  given  over  to  the  assistant,  and  the  bent  iris- 
forceps,  held  in  the  left  hand,  is  passed  closed  into  the  anterior 
chamber,  its  points  directed  toward  the  posterior  surface  of  the 
cornea,  so  as  to  avoid  entangling  them  in  the  iris.  When  the 
pupillary  margin  has  been  reached,  the  forceps  is  opened  as 
widely  as  the  corneal  incision  will  permit,  and  the  corresponding 
portion  of  iris  is  seized  and  drawn  out  to  its  full  extent  through 
the  corneal  incision.  AVith  the  scissors  held  in  the  other  hand, 
the  exposed  bit  of  iris  is  snipped  off  quite  close  to  the  corneal 
incision.  Care  should  now  be  taken  that  the  angles  of  the  colo- 
boma do  not  remain  in  the  wound  ;  and,  if  they  are  seen  to  do 
so,  they  may  be  reposed  by  stroking  the  region  of  the  incision 
with  a  hard-rubber  spoon,  or  by  actually  pushing  them  into 
their  places  gently  with  the  spatula. 

Iridotomy. — For  description  and   uses  of  this  operation  see 
Chap.  XIII. 

Cyclitis  (Inflammation  of   the  Ciliary    Body). 
Cyclitis  is  often  present  to  a  slight  degree  as  an  extension  of 
inflammatory    affections    of    the   iris   or    choroid,   although    its 
presence  in  many  of  these  cases  cannot  be  clinically  determined. 


248  DISEASES   OF    THE    EYE. 

The  Symptoms  of  Cyclitis  in  general  are :  marked  circum- 
corneal  injection,  ciliary  neuralgia,  pain  on  pressure  of  the 
ciliary  region,  very  deep  anterior  chamber,  opacity  in  the 
anterior  part  of  the  vitreous  humor,  and,  sometimes,  hypo- 
pyon in  the  anterior  chamber. 

There  are  three  forms  of  cyclitis : — 

1.  Plastic  Cyclitis. — Here  the  circumcorneal  injection  is  very 
decided,  and  there  is  venous  congestion  of  the  iris.  The  anterior 
chamber  is  deep,  owing  to  retraction  of  the  periphery  of  the  iris 
by  inflammatory  exudation  in  the  ciliary  body,  and,  for  the  same 
reason,  the  pupil  is  dilated.  The  inflammation  may  extend  to 
the  iris  or  to  the  choroid,  in  which  latter  case  the  vitreous 
may  become  very  opaque.  Violent  ciliary  pains  attend  the 
affection,  and  the  eyeball  is  very  tender  on  pressure  of  the 
ciliary  region.     The  intraocular  tension  is  reduced. 

2.  Serous  Cyclitis. — The  circumcorneal  injection  is  but  slight. 
The  anterior  chamber  is  often  at  first  deeper  than  normal, 
owing  to  hypersecretion  of  aqueous  humor  or  to  effusion  of 
fluid  inflammatory  products  from  the  ciliary  body,  there  is 
keratitis  punctata,  and  the  anterior  part  of  the  vitreous  humor 
is  filled  with  a  fine  dust-like  opacity.  Serous  iritis  may  come 
on,  and  the  danger  of  glaucomatous  increase  of  tension  is 
very  great.  Unless  increase  of  tension  give  rise  to  it,  pain 
does  not  often  attend  this  form. 

3.  Purulent  Cyclitis. — Here  the  circumcorneal  injection  is 
very  well  marked.  The  vitreous  humor  is  filled  with  mem- 
branous opacities.  There  is  hypopyon  in  the  anterior  chamber, 
which  has  the  characteristic  of  appearing  and  disappearing  at 
intervals  of  a  few  days.  There  is  severe  ciliary  neuralgia. 
Purulent  iritis,  or  choroiditis,  or  both,  are  apt  to  supervene. 

Prognosis. — In  an  early  stage  all  these  forms  are  capable  of 
undergoing  cure  and  of  leaving  the  eye  in  a  fairly  useful 
condition.  On  the  other  hand,  serous  cyclitis,  as  already 
stated,  is  liable  to  produce  secondary  glaucoma;  while  the 
purulent  form  leads  to  atrophy  of  the  iris  and  choroid,  dis- 
organization of  the  vitreous  humor,  detachment  of  the  retina. 


THE   CILIARY    BODY.  249 

cataract,  and  phthisis  bulbi ;  and  the  plastic  form,  in  addition 
to  serious  damage  to  the  affected  eye,  similar  to  that  produced 
by  purulent  cyclitis,  has,  more  than  either  of  the  other  forms, 
the  tendency  to  cause  sympathetic  uveitis  of  the  other  eye. 
The  shrunken  eyes  resulting  from  this  affection  are  often 
very  liable  to  attacks  of  inflammation,  and  frequently  remain 
painful  to  the  touch,  circumstances  which  indicate  that  chronic 
cyclitis  is  still  present,  and  consequently  such  stumps  are  a 
constant  source  of  danger  to  the  sound  eye. 

Causes. — Primary  idiopathic  cyclitis  is  a  rare  affection.  Trau- 
mata are  the  most  common  causes  of  the  affection.  Both  the 
plastic  and  the  purulent  form  are  liable  to  occur  after  cataract 
operations. 

The  Treatment  for  cyclitis  is  similar  to  that  for  iritis.  Leech- 
ing at  the  outer  canthus  is  often  of  great  benefit. 

Injuries  of  the  Ciliary  Body. 
Punctured  Wounds,  and  Foreign  Bodies  perforating  the  scler- 
otic at  a  distance  of  about  5  mm.  around  the  cornea,  are  almost 
certain  to  implicate  the  ciliary  body.  If  there  be  no  prolapse 
of  the  ciliary  body,  nor  any  foreign  body  in  the  interior  of  the 
eye,  the  sclerotic  wound  may  heal  by  aid  of  a  bandage  without 
further  ill  results.  If  a  prolapse  of  the  ciliary  body  or  iris  be 
present,  it  is  to  be  abscised  ;  and,  if  the  sclerotic  wound  be  large, 
it  may  be  thought  desirable  to  unite  its  margins  with  sutures. 
Wounds  of  the  ciliary  body  are  apt  to  cause  cyclitis,  especially 
if  the  former  be  caught  in  the  sclerotic  wound  in  healing,  or  if 
a  foreign  body  be  present  in  it,  or,  indeed,  anywhere  within  the 
eye;  and  this  traumatic  cyclitis  is  more  likely  to  produce  sym- 
pathetic ophthalmitis  than  the  idiopathic  form.  Hence,  a  region 
around  the  cornea  about  5  mm.  wide  is  aptly  termed  by  Nettle- 
ship  the  "  Dangerous  Zone." 

New^  Growths  of  the  Ciliary  Body. 
Sarcoma  occurs  here,  and  often  passes  unobserved,  until  it 
attains  considerable  size  as  a  brown  mass,  for  it  is  concealed 
from  view  by  the  iris.     Occasionally  it  makes  its  first  appearance 


250  DISEASES    OF    THE    EYE. 

at  the  angle  of  the  anterior  chamber.  Removal  of  the  eyeball  is 
indicated,  and  will  often  for  a  time  be  declined  by  the  patient, 
as  sight  may  be  but  slightly  affected  in  the  early  stages. 

Myosarcoma  originating  in  the  ciliary  muscle  has  been  ob- 
served a  few  times. 

Choroiditis. 

There  are  two  great  forms  of  inflammation  of  the  choroid,  the 
exudative  and  the  purulent.  Of  the  exudative  form,  again, 
there  are  several  kinds,  namely,  disseminated  choroiditis,  central 
choroiditis,  central  senile  choroiditis,  guttate  choroiditis,  and 
syphilitic  chorio-retinitis. 

Disseminated  Choroiditis. — The  usual  Ophthalmoscopic  Appear- 
ances  of  this  disease  consist  either  in  round  white  spots  of  dif- 
ferent sizes  with  irregular  black  margins,  or  in  small  spots  of 
pigment ;  these  changes  being  surrounded  by  healthy  choroidal 
tissue ;  or  there  may  be  few  or  no  white  patches,  but  rather 
spots  of  pigment  surrounded  by  a  pale  margin.  The  retinal 
vessels  pass  over,  not  under,  the  patches.  The  number  of  these 
patches  or  spots  varies,  according  to  the  intensity  of  the  disease. 
Their  position  is  at  first  at  the  periphery  of  the  fundus  only,  but 
later  on  they  appear  also  about  the  posterior  pole  of  the  eye. 

These  appearances  represent  a  rather  late  stage  of  the  disease, 
the  early  stage  not  usually  coming  under  observation.  It  con- 
sists in  small  circumscribed  plastic  exudations  into  the  tissue  of 
the  choroid,  which,  seen  with  the  ophthalmoscope,  give  the  ap- 
pearance of  pale  pinkish-yellow  spots.  The  exudations  may 
undergo  absorption,  leaving  the  choroid  in  a  fairly  healthy 
state ;  but,  more  usually,  they  give  rise  to  atrophic  cicatrices,  in 
which  the  retina  becomes  adherent,  with  proliferation  of  the 
pigment-epithelium  layer  in  their  neighborhood,  and  hence  the 
white  patches  with  black  margins  above  described. 

Sometimes,  in  addition  to  the  above  changes,  the  pigment- 
epithelium  layer  all  over  the  fundus  becomes  atrophied,  ex- 
posing to  view  the  vascular  network  of  the  choroid,  while  here 
and  there  small  islands  of  pigment  are  present. 

Opacities  in  the  vitreous  humor  are  sometimes  found. 


THE    CHOROID.  251 

Causes. — Disseminated  choroiditis  is  due  to  acquired  syphilis 
in  a  considerable  number  of  the  cases.  In  a  very  large  propor- 
tion of  cases  no  ascertainable  cause  exists ;  and  these,  there  is 
reason  to  suspect,  are  congenital,  and,  probably,  many  of  them 
dependent  on  an  inherited  syphilitic  taint.  In  eyes  with  con- 
genital cataract  patches  of  choroiditis  are  often  found. 

Prognosis. — Disseminated  choroiditis  is  always  a  serious  dis-. 
ease,  and  complete  recovery  cannot  be  looked  for.  The  degree 
of  defect  of  sight  it  causes  depends  much  on  the  extent  to  which 
the  region  of  the  macula  lutea  has  become  involved. 

Treatment. — In  fresh  cases  due  to  acquired  syphilis  a  pro- 
longed but  mild  course  of  mercurial  inunctions  is  the  most 
suitable  measure,  to  be  followed  by  a  lengthened  course  of 
treatment  with  iodide  of  potassium.  Where  an  inherited 
syphilitic  taint  is  suspected,  iodide  of  iron  or  iodide  of  potas- 
sium internally  may  be  of  use ;  while  in  the  cases  due  to 
other  causes,  small  doses  of  perchloride  of  mercury  may  be 
given ;  and  in  all  cases,  from  whatever  cause,  dry  cupping  on 
the  temple,  or  even  the  artificial  leech,  should  be  employed. 
Dark  protection  spectacles  should  be  worn,  and  absolute 'rest  of 
the  eyes  from  all  near  work  insisted  upon,  so  long  as  the  disease 
is  active. 

Syphilitic  Choroido-Retinitis. — See  Syphilitic  Retinitis,  Chap. 
XV. 

Central  Senile  Guttate  Choroiditis. — Under  this  name  an 
appearance  has  been  described  by  Mr.  Waren  Tay  and  others, 
which  consists  of  fine  white,  pale  yellow,  or  glistening  dots, 
best  seen  in  the  upright  image,  and  situated  chiefly  about 
the  macula  lutea,  or  between  this  and  the  optic  papilla. 
These  dots  are  due  to  colloid  degeneration  with  chalky  forma- 
tions in  the  vitreous  layer  of  the  choroid,*  which  give  rise 
to  secondary  retinal  changes.  The  functions  of  the  retina 
usually  suffer  in   a  marked    manner,  so  that  a  partial  central 

*Hir8chberg  and  others,  Centralbl.  f.  prakt.  Augenheilkvnde,  1884, 
p.  46. 


252  DISEASES   OF   THE   EYE. 

scotoma  may  be  produced,  but  some  cases  have  been  observed 
in  which  vision  was  but  little  or  not  at  all  affected. 

This  disease  attacks  both  eyes,  either  simultaneously  or  with 
an  interval,  and  is  most  often  seen  in  persons  of  advanced 
life,  although  also  found  in  middle  age,  and  even  in  youth. 
It  should  always  be  looked  for  in  cases  of  incipient  cataract; 
for  when  the  lental  opacity  is  more  advanced  it  cannot  be 
seen,  while  functional  examination  does  not  then  detect  it. 

Treatment  is  of  no  avail. 

Central  Choroiditis  is  an  exudation  at  the  macula  lutea, 
without  any  similar  disease  elsewhere  in  the  fundus.  Abso- 
lute central  scotoma  is  its  prominent  symptom,  and  syphilis 
its  usual  cause. 

Treatment. — Active  mercurialization  ;  and,  where  this  can  be 
adopted  early,  the  prognosis  for  recovery  of  sight  is  fair. 

Central  Senile  Areolar  Atrophy  of  the  Choroid. — Although 
this  is  not  an  inflammatory  process,  yet  it  is  most  convenient 
to  refer  to  it  here.  It  is  not  a  very  rare  disease,  and  presents 
the  appearance  of  a  white  patch,  often  of  considerable  extent, 
at  and  around  the  macular  region.  I  think  I  have  observed 
that,  in  some  cases,  a  hemorrhage  in  the  choroid  and  posterior 
layers  of  the  retina  formed  the  starting-point  of  the  disease. 
The  retinal  functions  always  suffer  much,  for  an  absolute 
central  scotoma  is  produced  which  renders  all  near  work 
impossible,  although  locomotion  is  not  much  impeded,  as  the 
periphery  of  the  field  remains  intact.  The  discovery  of  the 
presence  of  this  disease  after  a  cataract  has  been  successfully 
removed  is  sometimes  a  source  of  intense  disappointment,  both 
to  patient  and  surgeon,  which  cannot  be  guarded  against  unless 
it  has  been  noted  while  the  cataract  was  still  incipient. 

Treatment  is  of  no  avail. 

Purulent  Choroiditis. — This  consists  at  first  in  a  purulent  ex- 
travasation between  the  choroid  and  retina,  and  into  the  vitreous 
humor,  recognizable  by  the  yellowish  reflection  obtained  from 
the  interior  of  the  eye  on  illuminating  it.  The  eyeball  may  be- 
come hard,  the  pupil  dilated,  and  the  anterior  chamber  shallow. 


THE   CHOROID.  253 

Purulent  iritis  with  hypopyon  soon  comes  on,  and  the  cornea 
may  also  become  infiltrated  and  slough  away.  There  is  usually 
considerable  chemosis.  The  eyeball  is  pushed  forward  by 
inflammatory  infiltration  of  the  orbital  connective  tissue.  The 
eyelids  are  swollen  and  congested.  There  is  intense  pulsating 
pain  in  the  eye  and  radiating  pains  through  the  head  ;  and  in 
this  stage  all  the  tissues  of  the  eyeball  are  engaged  in  the 
purulent  inflammation,  and  the  condition  is  termed  Panophthal- 
mitis. 

Purulent  choroiditis  does  not  always  reach  this  latter  stage, 
but  may  remain  confined  chiefly  to  the  choroid,  vitreous  humor, 
and  iris.  The  pain  in  such  cases  is  not  severe,  and  when  the  af- 
fection occurs  in  children  it  may  be  mistaken  for  glioma  ;  indeed, 
the  name  pseudoglioma  has,  unfortunately,  been  given  to  it.  It 
is  distinguished  from  the  malignant  disease  by  the  muddy  vit- 
reous usually  present  in  it,  by  the  posterior  synechise,  and  by 
the  retraction  of  the  iris  periphery,  with  bulging  forward  of  its 
pupillary  part. 

Prognosis. — The  ultimate  result,  in  the  vast  majority  of  cases, 
is  loss  of  sight,  with  phthisis  bulbi.  The  severe  cases  go  on  to 
bursting  of  the  eyeball  through  the  cornea  or  sclerotic,  after 
which  the  pain  subsides.  It  would  seem  from  the  description 
of  authors  who  have  seen  much  of  epidemic  cerebro-spinal  men- 
ingitis (Niemeyer),  that  a  certain  number  of  cases  of  irido- 
choroiditis  occurring  in  the  course  of  that  disease,  do  recover 
with  retention  of  good  sight. 

The  shrunken  eyeballs  produced  by  panophthalmitis  are  not 
generally  painful  on  pressure,  nor  are  they  very  liable  to  give 
rise  to  sympathetic  ophthalmitis  ;  which  latter  observation  is 
also  true  of  the  acute  purulent  process  itself. 

Causes. — The  most  common  causes  of  purulent  choroiditis  are 
wounds  of  the  eyeball,  whether  accidental  or  operative  (especi- 
ally cataract  extractions),  foreign  bodies  piercing  and  lodging 
in  the  eyeball,  and  purulent  keratitis.  It  may  also  come  on  sud- 
denly in  eyes  which  are  the  subjects  of  incarceration  of  the 
iris  in  a  corneal  cicatrix. 


254  DISEASES    OF   THE    EYE. 

It  is  seen  as  embolic  or  metastatic  choroiditis,  iu  connec- 
tion botli  with  epidemic  and  sporadic  cerebro-spinal  mening- 
itis ;  in  some  cases  of  metria,  similarly  as  purulent  retinitis 
(Chap.  XV) ;  in  pyaemia  of  the  ordinary  type,  and  in  endo- 
carditis. 

In  infancy  and  childhood,  besides  its  occurrence  with  cerebro- 
spinal-meningitis,  it  has  been  known  to  be  caused  by,  or 
associated  with,  inherited  syphilis,  measles,  bronchitis,  diarrhoea, 
whooping  cough,  and  omphalo-phlebitis  ;  and  it  is  more  than 
probable  that  in  every  instance  some  infective  blood-disease  is 
the  fundamental  cause  of  the  process,  although  it  may  not 
always  be  possible  to  detect  the  existence  of  that  blood  dis- 
ease. 

Treatment  may  be  said  to  be  powerless  in  this  disease.  The 
most  one  can  do  is  to  try  to  diminish  the  pain  by  warm  fomenta- 
tions, poultices  containing  powdered  conium  leaves,  hypodermic 
injections  of  morphium,  or,  finally,  by  giving  exit  to  the  pus  by 
a  free  incision  in  the  eyeball,  followed  by  a  copious  irrigation 
with  weak  sublimate  lotion,  so  as  to  wash  out  the  whole  con- 
tents of  the  scleral  cavity.  Quinine  and  chlorate  of  potash  are 
suitable  internal  remedies. 

I  agree  with  those  who  think  that  enucleation  of  the 
eyeball  should  not  be  undertaken  during  purulent  choroid- 
itis in  the  acute  stage,  as  it  is  liable  to  lead  to  purulent 
meningitis  and  death  ;  but  there  are  surgeons  who  do  not  recog- 
nize any  such  danger,  and  who  practice  enucleation  in  this 
condition. 

Posterior  Sclero-Choroiditis,  or  Posterior  Staphyloma. — 
This  condition  is  described  in  connection  with  myopia  (Chap. 
II,  p.  36),  which  is  its  almost  constant  cause. 

Detachment  of  the  Choroid.— As  the  result  of  copious  loss 
of  vitreous,  during  operations  or  from  injury,  detachment  of 
the  choroid  is  not  uncommon,  but  it  does  not  require  to  be 
specially  diagnosed  in  these  instances,  and  therefore  it  is  not 
important  to  consider  it  further  here. 

But   idiopathic    detachment    of  the    choroid,    although    ex- 


THE    CHOROID.  255 

tremely    rare,*   is    of    importance    as    forraiug    a    well-defined 
diseased  condition  in  itself. 

The  Ophthalmoscopic  Appearances  here  are  apt  to  be  taken  at 
first  glance  for  detachment  of  the  retina  simply.  Bnt  on 
closer  inspection  the  choroidal  stroma  is  observed  to  lie  im- 
mediately behind  the  detached  retina,  and  its  vessels,  etc., 
are  seen  in  the  upright  image  by  aid  of  the  same  lens  as 
are  the  retinal  vessels.  The  choroid  is  not  completely  detached, 
but  is  separated  from  the  sclerotic  in  several  ditierent  places, 
and  these  detachments  are  seen  in  the  form  of  apparently 
solid  hemispherical  protuberances  rising  abruptly  from  the 
fundus  into  the  vitreous  humor.  In  other  places  the  choroid  is 
in  contact  with  the  sclerotic,  although  in  some  of  these  posi- 
tions there  may  be  detachment  of  the  retina  alone.  The 
vitreous  humor  is  more  or  less  opaque.  Xeedlesa  to  say,  vision 
is  greatly  lowered  or  quite  destroyed. 

It  is  probable  that  a  chronic  choroido-retinitis  has  been  an 
antecedent  condition  in  all  of  these  cases.  Indeed,  there 
often  are  signs  of  old  retinitis  present,  such  as  perivasculitis 
and  connective  tissue  striation ;  and,  in  one  case,  a  retinitis 
was  actually  observed  long  before  the  detachment  of  the 
choroid  came  on.  Adhesions  between  the  choroid  and  sclerotic 
are  formed  in  consequence  of  this  inflammation,  and  then 
inflammatory  exudation  takes  place  behind  the  choroid,  and 
separates  it  from  the  sclerotic  where  it  happens  not  to  be 
adherent  to  the  latter. 

The  process  ends  either  in  phthisis  bulbi,  in  consequence  of 
vascular  changes  and  disturbances  of  nutrition,  or  in  cure 
of  a  certain  kind,  in  so  far  as  by  absorption  of  some  of  the 
exudation,  and  by  alteration  of  the  remainder  of  it  into 
connective  tissue,  a  return  of  the  choroid  and  retina  to  their 
normal  position  is  rendered  possible ;  but,  even  then,  restora- 
tion of  sight,  with  tunics  so  disorganized,  cannot  be  looked  for. 

*  The  most  recent  case  of  the  kind,  and  one  of  the  best  observed,  is 
reported  by  Story  in  Trans.   Ophth.  Soc,  1S91,  p.  12. 


256  DISEASES   OF   THE    EYE. 

Treatment  hitherto  seems  to  have  been  of  no  avail.  Pro- 
bably active  mercurialization  might  afford  the  best  chance  of 
doing  good,  should  a  case  come  under  notice. 

Injuries  of  the  Choroid. 

Small  Foreign  Bodies  may  pierce  the  sclerotic,  or  the 
cornea  and  lens,  and  lodge  in  the  choroid,  and  can  often  there 
be  detected  with  the  ophthalmoscope.  They  require  operative 
removal  by  the  magnet,  if  metallic;  or  if  this  cannot  be 
carried  out,  or  that  the  foreign  body  is  non-metallic,  the  eye- 
ball must  be  removed,  to  avert  sympathetic  ophthalmitis. 

Incised  Wounds  of  the  sclerotic  very  frequently  involve  the 
choroid  (see  p.  228). 

Rupture  of  the  Choroid  is  often  produced  by  blows  on 
the  eye,  and  is  seen  with  the  ophthalmoscope  as  a  whitish- 
yellow  (the  color  of  the  sclerotic)  crescent  some  two  or  three 
papilla-diameters  in  length  and  one  or  so  distant  from  the 
optic  entrance,  the  concavity  of  the  crescent  being  directed 
toward  the  papilla.  Immediately  after  the  accident,  extra- 
vasated  blood  sometimes  prevents  a  view  of  the  rupture. 
Some  choroiditis  may  result,  but  when  this  passes  away 
good  vision  is  frequently  restored  and  maintained,  provided 
detachment  of  the  retina  does  not  ultimately  supervene  from 
cicatricial  contraction  at  the  seat  of  the  rupture. 

Treatment. — Careful  protection  of  the  eye,  and  abstinence 
from  use  of  it,  with  dry  cupping  at  the  temple. 

New  Growths  of  the  Choroid. 

Sarcoma. — This  is  by  far  the  most  common  neoplasm  of  the 
choroid,  and  is  seen  at  all  times  of  life,  but  most  frequently 
between  the  ages  of  40  and  60.  When  highly  pigmented,  it  is 
termed  melano  sarcoma.  It  may  originate  in  any  part  of  the 
choroid. 

If  seen  in  a  very  early  stage,  it  is  easily  recognized  from  its 
projecting  over  the  general  surface  of  the  fundus;  but,  unless 
it  be   in    the   region    of    the  macula  lutea,  it   may  not   cause 


THE   CHOROID.  257 

auy  serious  disturbance   of  vision,  and  hence  may  not  at  that 
period  be  brought  under  the  notice  of  the  surgeon. 

The  new  growth  soon  gives  rise  to  detachment  of  the  retina 
by  reason  of  serous  exudation  from  the  choroid,  and  this  is  ac- 
companied by  opacity  in  the  vitreous  humor,  which  renders  the 
diagnosis  with  the  ophthalmoscope  difficult  or  impossible.  If 
the  detachment  be  shallow  and  the  retina  translucent,  the 
tumor  may  still  sometimes  be  seen  through  the  subretinal  fluid 
by  aid  of  strong  illumination ;  and  even  direct  sunlight  may  be 
employed  in  some  such  cases.  Owing  to  the  great  defect  of 
vision  which  comes  on  in  this  stage,  we  very  commonly  see 
these  cases  then  for  the  first  time.  The  history  of  the  case  may 
aid  us ;  and  the  absence  of  the  more  usual  causes  of  detachment 
of  the  retina  should  make  us  suspicious  of  an  intraocular  tumor. 

Soon  the  intraocular  tension  increases  ;  and  this  makes  the 
diagnosis  again  more  easy  in  many  cases,  for  the  combination  of 
detached  retina  and  increased  tension  exists  only  with  intra- 
ocular tumors.  The  increased  tension  may  come  on  very 
slowly  and  without  ciliary  neuralgia,  or  more  rapidly  and 
with  all  the  signs  and  symptoms  of  acute  glaucoma.  Still,  if 
the  case  come  now  under  observation  for  the  first  time,  the 
diagnosis  may  be  by  no  means  easy,  should  the  refracting  media 
be  opaque  (as  always  in  acute  glaucoma),  and,  consequently,  the 
detachment  of  the  retina  be  concealed  from  view.  Here,  again, 
the  history  of  the  case  is  all  we  have  to  depend  on,  especially 
the  fact  of  the  patient  having  noticed  a  defect  at  one  side  of  his  - 
field  of  vision  previous  to  the  onset  of  glaucoma. 

In  the  next  stage  of  the  growth  it  perforates  the  cornea  or 
sclerotic,  and,  increasing  rapidly  in  size,  although  still  covered 
with  conjunctiva,  it  pushes  the  eyeball  to  one  side,  the  upper  lid 
being  stretched  tightly  over  the  whole.  On  raising  the  lid  the 
tumor  is  seen  as  a  bluish-gray  mass  of  irregular  surface.  The 
conjunctiva  is  now  soon  perforated,  and  the  surface  of  the  tumor 
becomes  ulcerated,  with  a  foul-smelling  discharge  and  occasional 
hemorrhages.  The  tumor  gradually  invades  the  surrounding 
22 


258  DISEASES   OF   THE   EYE. 

skin  and  the  bones  of  the  orbit,  and,  by  extending  through  the 
sphenoidal  fissure  and  optic  foramen,  reaches  the  base  of  the 
brain. 

It  is,  usually,  upon  the  neighboring  tissues  of  the  eyeball 
becoming  involved,  that  secondary  growths  begin  to  form  in 
other  organs,  the  one  most  prone  to  be  affected  being  the  liver. 
The  lungs,  stomach,  peritoneum,  spleen,  and  kidneys  may  all  be 
attacked. 

Choroidal  sarcoma  is  almost  always  primary,  but  it  has  been 
seen  a  few  times  as  a  metastatic  disease. 

The  entire  progress  of  such  a  growth  varies  considerably.  It 
may  occupy  but  a  few  months,  or  it  may  extend  over  many 
years. 

Carcinoma. — This  is  extremely  rare,  and  the  cases  of  it  on 
record  were  all  of  metastatic  origin,  the  primary  disease  being 
in  the  breast.  It  is  not  possible  to  distinguish  choroidal  sar- 
coma from  choroidal  carcinoma  by  the  ophthalmoscope. 

Tubercle  is  sometimes  seen  in  cases  of  acute  miliary  tubercu- 
losis as  round,  slightly  prominent,  pale  yellowish  spots,  of  sizes 
varying  from  0.5  to  2.5  mm.  in  diameter,  situated  always  in  the 
neighborhood  of  the  optic  papilla  and  macula  lutea,  and  unac- 
companied by  pigmentary  or  other  choroidal  changes.  There 
may  be  but  one  of  these  tubercles,  or  there  may  be  many  of 
them.  They  occur,  as  a  rule,  in  a  late  stage  of  the  general 
disease,  but  have  occasionally  been  noted  long  before  its  ap- 
pearance. In  obscure  cases  of  the  general  disease  the  ophthal- 
moscope has  sometimes  rendered  valuable  diagnostic  aid  by 
discovering  these  minute  tubercles  in  the  choroid. 

Very  rarely,  a  tubercular  tumor  grows  in  the  choroid  in  cases 
of  general  chronic  tuberculosis,  and  attains  a  large  size,  the 
growth  destroying  the  eye  similarly  as  sarcoma  or  carcinoma. 
In  young  children  it  may  be  impossible  to  diagnose  between  a 
tubercular  tumor  of  the  choroid  and  a  glioma  of  the  retina 
(Chap.  XV).  As  in  either  case  enucleation  is  indicated,  the 
diagnosis  is  not  of  much  practical  importance. 


THE    CHOROID.  259 

Other,  but  rare,  forms  of  tumor  of  the  choroid  are : — 

Sarcoma  Carcinomaiosum,^  and,  in  a  case  of  ray  own,  Osteo- 
Sarcoma. f 

Treatment. — So  long  as,  in  cases  of  sarcoma  and  carcinoma, 
the  tumor  is  wholly  intraocular,  enucleation  of  the  eyeball 
should  be  performed,  and  may  be  done  with  fair  hopes  of  sav- 
ing the  patient's  life  if  the  disease  be  primary.  When  the 
orbital  tissues  have  become  involved,  extirpation  of  all  the  con- 
tents of  the  orbit,  and  even,  if  necessary,  removal  of  portions 
of  its  bony  walls,  ought  to  be  undertaken  should  the  general 
health  permit,  in  order  to  rid  the  patient  of  his  loathsome  dis- 
ease, although  the  probable  presence  of  secondary  growths  else- 
where renders  but  small  the  prospect  of  saving  the  patient's 
life. 

Cases  of  miliary  choroidal  tubercle  do  not  call  for  direct 
treatment.  In  cases  of  tubercular  tumor,  the  question  of  re- 
moval of  the  eyeball  must  depend  upon  the  general  state  of  the 
patient ;  but,  if  it  seem  probable  that  life  will  be  prolonged 
until  after  the  ocular  growth  has  become  extraocular,  removal 
of  the  eye  should  be  recommended. 

Congenital  Defects  of  the  Choroid. 
Coloboma. — This  is  a  solution  of  continuity  occurring  always 
in  the  lower  part  of  the  choroid,  and  usually  associated  with  a 
similar  defect  in  the  iris.  It  may  commence  at  the  optic  papilla 
and  involve  the  ciliary  body  also,  and  even  the  crystalline  lens 
may  have  a  corresponding  notch,  or  it  may  not  extend  so  far 
in  either  direction.  The  condition  is  recognized  ophthalraoscop- 
ically  by  the  white  patch  due  to  exposure  of  the  sclerotic  where 
the  choroid  is  deficient.  Sometimes  the  retina  is  absent  over  the 
defect  in  the  choroid,  a  circumstance  which  may  be  ascertained 
by  the  arrangement  of  the   retinal  vessels;  but,  even  if  it  be 

*  Von  Graefe'sArchiv,  x,  pt.  1,  p.  179;  Landsberg,  Archiv,  f.  Ophthal., 
xi,  pt.  1,  p.  58 ;  Trans.  Acad.  Med.  in  Ireland,  i,  p.  47. 
^  Bericht  der  ffeidelberger,  Ophthal.  Gesellsch.,  1883. 


260  DISEASES    OF   THE    EYE. 

present,  its  functions  at  the  place  are  wanting,  and  a  defect  in 
the  field  of  vision  exists.     Central  vision  is  often  normal. 

Albinismus,  or  the  want  of  pigment  in  the  choroid  and  iris. 
This  is  usually  accompanied  by  defective  pigmentation  of  the 
hair  of  the  body.  The  iris  has  a  pink  appearance,  due  to  reflec- 
tion of  light  from  its  blood-vessels  and  from  those  of  the  choroid, 
and,  with  the  ophthalmoscope,  the  latter  vessels  can  be  seen 
down  to  their  finest  branchings.  The  light,  not  being  partially 
absorbed  by  pigment,  causes  the  patient  much  dazzling,  and  high 
degrees  of  the  condition  are  usually  accompanied  by  nystagmus. 
In  childhood  the  albinismus  and  attendant  symptoms  are  more 
marked  than  later  on,  when  some  degree  of  pigmentation  usually 
takes  place. 

Much  advantage  may  be  derived  in  many  of  these  cases  by 
the  use  of  stenopeic  spectacles,  at  least  for  near  work.  Any 
defect  of  refraction  should  be  carefully  corrected. 

Sympathetic  Ophthalmitis. 

By  this  term  we  understand  a  uveitis  (irido-cyclitis,  irido- 
choroiditis)  caused  by  an  irido-cyclitis  of  the  other  eye,  the 
latter  being  usually  of  traumatic  origin. 

The  affection  owes  its  name  to  the  theory,  held  until  a  few 
years  ago,  that  it  was  due  to  reflex  action  of  the  ciliary  nerves. 
Although  this  view,  which  is  no  longer  in  accord  with  modern 
pathology,  has  given  place  to  another,  yet  the  original  name  of 
the  disease  is  still  retained,  and  we  often  speak  of  the  injured 
eye  as  *' the  exciting  eye,"  while  the  secondarily  affected  eye  is 
called  the  "sympathizing  eye." 

The  cyclitis  most  likely  to  cause  sympathetic  ophthalmitis  is 
that  set  up  by  a  punctured  wound  of  the  eyeball,  especially  a 
wound  involving  the  ciliary  body.  The  cyclitis  set  up  by  a 
foreign  body  which  pierces  the  tunics  of  the  eye  and  lodges 
in  its  interior  is  also  of  serious  import,  even  though  the 
ciliary  body  may  not  have  been  injured.  Perforating  corneal 
ulcers,  and  even  simple  incisions  of  the  cornea,  may  form  the 
starting-point  of  sympathetic  ophthalmitis.     It  is  an  important 


SYMPATHETIC   OPHTHALMITIS.  261 

and  interesting  fact  that  eyes  which  are,  or  have  been,  the  sub- 
ject of  purulent  panophthalnaitis  do  not  give  rise  to  sympathetic 
ophthalmitis. 

There  is  considerable  doubt  as  to  whether  sympathetic  oph- 
thalmitis can  occur  without  a  perforating  lesion  of  the  exciting 
eye.  It  has  been  held  that  a  dislocated  crystalline  lens,  or 
cyclitis  caused  by  a  blow  on  the  eye,  could  serve  as  excitants 
of  sympathetic  ophthalmitis;  but,  if  such  cases  do  occur,  they 
are  very  rare.    I  have  myself  never  seen  an  instance  of  the  kind. 

In  cases  of  sympathetic  ophthalmitis,  the  cyclitis  of  the  ex- 
citing eye  may  be  but  slight,  so  slight,  indeed,  that  vision  is  not 
seriously  affected,  or  it  may  be  severe.  The  degree  of  severity 
of  the  attack  in  the  sympathizing  eye  does  not  depend  on  that 
of  the  inflammation  in  the  exciting  eye ;  for,  in  many  cases, 
the  process  in  the  sympathizing  eye  is  a  more  severe  one  and 
more  destructive  to  sight  than  that  in  the  exciting  eye. 

Sympathetic  ophthalmitis  is  met  with  in  persons  of  every  time 
of  life,  but  children  under  the  age  of  puberty  are  more  prone  to 
it  than  in  later  years. 

Syinjyathetic  Invitation,  or  Neurosis,  is  a  condition  of  the  second 
eye  sometimes  seen,  and  which  must  not  be  confounded  with 
sympathetic  ophthalmitis,  nor  is  it  to  be  regarded  as  a  pre- 
monitory sign  of  the  latter,  for  it  may  pass  away  without 
leaving  any  organic  changes  behind  it.  It  consists  in  photo- 
phobia, lachrymation,  pericorneal  injection,  and  accommodative 
asthenopia,  and  is,  very  probably,  a  reflex  neurosis. 

Premonitory  Sign  of  Sympathetic  Ophthalmitis. — Shrinking  pain 
(the  patient  draws  back  his  head  in  a  most  characteristic  way) 
on  pressure  of  the  ciliary  region  of  the  exciting  eye  is  almost 
always  present  where  sympathetic  ophthalmitis  supervenes ; 
although  it  does  not  necessarily  indicate  that  the  latter  is 
imminent,  nor  even  that  its  ultimate  appearance  is  certain. 
But  there  are  no  premonitory  signs  in  the  sympathizing  eye 
prior  to  the  attack  of  inflammation  in  it. 

Progress  of  Sympathetic  Ophthalmitis. — Slight  optic  neuritis 
has  been  noticed  in  the  sympathizing  eye  in  some  cases  prior 


262  DISEASES   OF   THE    EYE. 

to,  or  simultaneously  with,  the  outbreak  of  irido-cyclitis,  and 
is,  probably,  of  tolerably  constant  occurrence.  But  it  is  not 
the  sign  or  symptom  which  commonly  first  attracts  the  atten- 
tion of  the  patient  or  of  the  surgeon.  The  process  is  usually 
first  observed  in  the  sympathizing  eye  as  a  serous  irido-cy- 
clitis, with  increased  depth  of  the  anterior  chamber  and 
keratitis  punctata,  and  may  maintain  this  character  to  the 
end.  As  a  rule,  it  soon  passes  over  to  a  plastic  form  with 
development  of  new  vessels  in  the  iris  and  shallowness  of 
the  anterior  chamber.  The  tissue  of  the  iris  and  ciliary 
body  becomes  infiltrated  with  lymph  cells,  and  on  their 
posterior  surfaces  and  in  the  pupil  a  deposit  of  lymph  cells 
takes  place,  the  choroid  also  becoming  similarly  infiltrated, 
and  connective  tissue  is  developed  in  its  exudation.  The 
vessels  of  the  uveal  tract  are  destroyed  by  pressure  of  the 
newly-developed  connective  tissue ;  the  vitreous  humor  con- 
sequently shrinks,  causing  detachment  of  the  retina,  cataract, 
and  phthisis  bulbi. 

Or  the  process  may  be  confined  chiefly  to  the  anterior 
segment  of  the  eyeball,  the  iris,  ciliary  body,  and  lens,  and 
may  merely  cause  disorganization  of  those  parts  with  shallow 
anterior  chamber — a  condition  known  as  phthisis  anterior — 
while  the  vitreous  humor,  retina,  and  choroid  remain  healthy. 
In  such  cases,  of  course,  vision  is  much  damaged.  Or,  again, 
very  occasionally,  in  some  mild  cases,  the  exudation  may  be- 
come absorbed,  and  leave  a  tolerably  clear  pupil  and  media, 
with  more  or  less  useful  sight. 

The  shortest  period  at  which,  after  irido-cyclitis  has  been 
set  up  in  the  injured  eye,  sympathetic  ophthalmitis  is  liable 
to  appear,  seems  to  be  about  twelve  or  fourteen  days,  and  the 
longest  about  twenty  years.  The  most  usual  interval  is  from 
six  to  eight  weeks. 

Nature  of  the  Disease. — Investigations  made  in  recent  years* 


*  Knies,  Sitzungsber  d.  Ophth.  GeseUsch  ,  1879,  p.  52;  Leber,  A.  v. 
Graefe's  Archiv,  xxvii,  pt.  1,  p.  325  ;  Brailey,  Trans.  Internat.  Med.  Con- 


SYMPATHETIC   OPHTHALMITIS.  263 

have  placed  it  beyond  doubt  that  sympathetic  ophthalmitis  is 
an  inflammation,  propagated  to  the  sympathizing  eye  by  direct 
continuity  through  the  optic  nerves  and  chiasma  from  the 
exciting  eye,  as  erysipelas  extends  over  the  skin,  and  that  the 
micro-organism  known  as  Staphylococcus  pyogenes  albus,  or 
aureus,  is  the  active  element  in  the  process.  This  fact  has 
suggested  the  term  Migratory  Ophthalmitis  for  the  disease. 

Prognosis. — This  disease  is  one  of  the  most  serious  to  which 
the  eye  is  liable,  leading,  as  it  does,  in  the  vast  majority 
of  cases,  to  absolute  and  incurable  blindness.  It  is  but 
rarely  that  the  sympathizing  eye  escapes  with  some  useful 
vision. 

Treatment. — The  most  important  point  is  the  prevention  of 
the  extension  of  the  inflammation  to  the  other  eye.  Sir  W. 
Bowman  *  found  it  possible,  in  private  practice,  by  careful 
nursing  for  a  year  or  more,  to  save  some  eyes  with  severe 
wounds,  and  to  prevent  the  occurrence  of  sympathetic  ophthal- 
mitis. 

Abadie  recommends  t  that,  when  the  case  comes  under 
treatment  early,  antiseptic  measures  be  taken  to  prevent 
infection ;  and  that,  if  these  fail,  the  actual  cautery  be 
applied  to  the  wound  ;  and  that,  if  this  be  not  enough,  one 
or  two  drops  of  a  1  in  1000  solution  of  sublimate  be  injected 
into  the  wounded  eye,  and  where  the  second  eye  has  become 
aflfected,  one  or  two  drops  of  the  same  solution  be  injected 
into    the  vitreous   humor  of    that   eye.     He    has   found    these 

gress^  1881,  vol.  iii ;  Snellen,  Trans.  Internat.  Med.  Congress^  1881, 
vol.  iii ;  Macgillivray,  Amsterdam  Internat.  Med.  Congress^  1879  ;  Berlin, 
Volkmann' s  Samml.  Klin.  Vortrdge,  No.  185,  1880 ;  Deutschmann,  A.  v. 
Graefe's  Archiv,  xxx,  pt.  3,  p.  77,  xxxi,  pt.  2,  p.  277,  and  "  Ueber  die 
Ophthalmia  Migratoria,"  1889  ;  Gifford,  Archivesof  Ophthalmology,  1886, 
p.  281.  Randolph,  in  Arch,  of  Ophthal.,  vol.  xvii,  p.  188,  does  not 
support  the  theory  of  extension  of  the  process  through  the  optic  nerves 
and  chiasma,  but  he  does  not  offer  an  alternative  explanation. 

*  Ophthal  Rev.,  1882,  p.  228. 

t  Annates  d''  OcuUstique,  Mars-Avril,  1890. 


264  DISEASES   OF   THE    EYE. 

injections   of   use   in    checking,   or   ameliorating,   sympathetic 
ophthalmitis. 

But  the  only  measures  generally  admitted  to  be  certain 
prophylactics,  when  employed  in  time,  and  the  only  ones 
applicable  to  the  great  mass  of  those  with  whom  we  have  to 
deal,  are  removal  of  the  injured  eye,  evisceration,  and  Mules's 
operation ;  and  a  most  difficult  question  sometimes  presents 
itself  when,  in  a  given  case,  we  have  to  decide  as  to  the 
necessity  for  one  of  these  measures.  The  following  rules  guide 
me  in  ray  own  practice  at  present : — 

1.  Although  danger  to  the  second  eye  practically  does  not 
arise  until  inflammation  has  been  set  up  in  the  exciting 
eye,*  yet  I  would  perform  primary  enucleation,  evisceration, 
or  Mules's  operation  on  the  latter  if  it  had  been  so  injured  as 
to  make  recovery  of  sight  almost  hopeless,  and  the  onset  of 
irido-cyclitis  almost  certain. 

2.  I  would  enucleatet  in  the  same  case,  were  irido-cyclitis 
already  set  up  in  the  injured  eye. 

3.  I  would  enucleate  in  a  case  of  irido-cyclitis  where  a  foreign 
body  which  could  not  safely  be  extracted  was  present  in  the 
eye,  even  though  the  vision  were  fairly  good ;  because  we  know 
that  here  the  danger  of  sympathetic  ophthalmitis  amounts  almost 
to  a  certainty. 

4.  I  would  enucleate  in  a  case  of  acute  irido-cyclitis,  traumatic 
or  idiopathic,  where  vision  was  lost,  especially  if  the  eye  were 
tender  on  pressure ;  for  here  the  eyeball  is  useless  and  disfigur- 
ing, and  apt  to  be  a  source  of  danger  to  its  fellow. 

5.  I  would  enucleate  in  a  case  of  phthisis  bulbi,  even  of  old 
standing,  where  there  was  shrinking  pain  on  pressure,  for  the 
same  reasons  as  in  Xo.  4. 

*  A  few  cases  are  recorded  in  which,  although  the  exciter  was  removed 
almost  immediately  after  the  injury,  yet  sympathetic  ophthalmitis 
supervened. 

t  For  the  sake  of  brevity,  the  word  enucleation  only  is  used  in  what 
follows,  but  evisceration,  or  Mules's  operation,  is  equally  implied. 


SYMPATHETIC   OPHTHALMITIS.  265 

6.  I  would  enucleate  in  a  case  where  the  sympathizing  eye  is 
already  affected,  provided  vision  in  the  exciting  eye  be  lost  and 
hopes  of  its  recovery  but  slight,  if  any  ;  for  improvement  in  the 
sympathizing  eye,  or  a  greater  amenability  of  it  to  treatment, 
has  been  frequently  observed  after  this  has  been  done.  Brailey, 
however,  holds  that  enucleation  is  not  in  this  instance  to  be  rec- 
ommended, as  he  believes  it  tends  to  aggravate  the  condition  of 
the  sympathizing  eye — to  change  a  serous  into  a  plastic  uveitis. 

7.  I  would  enucleate  in  a  case  of  sympathetic  irritation,  if  the 
sight  of  the  exciting  eye  were  very  defective  and  the  neurosis 
very  persistent. 

1a.  I  would  not  remove  any  injured  eye,  unless  it  contained  a 
foreign  body  which  I  could  not  extract,  if  its  sight  were  fairly 
good,  and  as  yet  no  sign  of  inflammation  present.  For  inflam- 
mation may  not  come  on,  and  the  eye  may  possibly  be  saved. 

2a.  I  would  not  enucleate  the  exciting  eye,  if  sympathetic 
ophthalmitis  had  already  appeared,  should  the  vision  of  the  ex- 
citing eye  be  fairly  good.  (Contrast  this  with  Rule  6.)  For  it 
often  occurs  that  the  process  in  the  sympathizing  eye  is  not  ar- 
rested by  the  proceeding,  and  that,  where  the  latter  is  not  under- 
taken, the  exciting  eye  turns  out  in  the  end  to  be  the  organ  with 
the  better  vision. 

Cases  have  been  observed  in  which  sympathetic  ophthalmitis 
broke  out  some  days  after  removal  of  the  exciting  eye.  In  these 
•instances  the  inflammation,  no  doubt,  had  already  started  on  its 
journey  from  the  exciting  eye,  the  removal  of  which  did  not  ar- 
rest its  progress.  Inasmuch,  then,  as  the  inflammation  takes 
some  twelve  to  fourteen  days  (vide  supra)  to  travel  from  one  eye  to 
the  other,  one  cannot  feel  certain  of  having  averted  sympathetic 
ophthalmitis  before  that  period  at  least  has  elapsed  after  enucle- 
ation of  the  exciter ;  and  it  is  well  to  impose  abstinence  from 
use  of  the  eye,  or  exposure  of  it  to  much  light,  for  that  time  or 
longer.  This  fact  is  not  to  deter  the  surgeon  from  recommend- 
ing enucleation  when  indicated,  for  in  the  vast  majority  of 
cases  it  has  the  desired  effect,  and  even  in  the  cases  where 
sympathetic  ophthalmitis  was  not  averted,  the  inflammation  in 
23 


266  DISEASES   OF   THE    EYE. 

the  sympathizer  was  usually  of  a  mild  type  and  yielded  to 
treatment. 

As  substitutes  for  enucleation  of  the  eyeball  in  these  cases, 
division  of  the  optic  nerve  in  the  orbit  (optic  neurotomy), 
resection  of  a  piece  of  the  optic  nerve  in  the  orbit  (optic 
neurectomy),  and  evisceration  or  exenteration  of  the  eyeball, 
have  all  been  proposed  and  practiced. 

Optic  Neurotomy  is  still  employed  by  some  surgeons  ;  but  by 
most  it  has  been  abandoned,  under  the  impression  that  it  does 
not  afford  good  protection  against  sympathetic  ophthalmitis; 
for  the  cut  ends  of  the  nerves  reunite,  and  at  least  one  case* 
has  been  observed  in  which,  several  months  after  the  optic 
neurotomy,  sympathetic  ophthalmitis  appeared. 

Optic  Neurectomy  was  first  advocated  by  Schweigger,  f  and 
is,  in  his  opinion,  a  better  protective  than  enucleation.  The 
views  of  other  surgeons  have  not  yet  been  published,  and  I 
have  myself  too  little  experience  of  the  method  to  form  an 
opinion  on  it,  but  it  would  seem  to  recommend  itself  as 
rational. 

Evisceration  is  still  on  its  trial  as  a  prophylactic  measure 
for  sympathetic  ophthalmitis.  A  few  cases  {  are  on  record  in 
which  the  good  eye  became  affected  not  long  after  evisceration 
of  the  exciting  eye,  but  this  has  taken  place,  too,  as  above 
stated,  after  enucleation  ;  and  so  far  as  we  can  yet  form  an 
opinion,  the  prophylactic  value  of  evisceration  is  at  least  as 
great  as  that  of  enucleation.  The  mode  of  performing  the 
operation,  and  Mr.  Mules's  modification  of  it,  are  given  at  pp. 
214  and  215.  The  indications  for  these  various  procedures  are 
the  same  as  for  enucleation. 

Sympathetic  ophthalmitis  having  broken  out,  and  the  ques- 
tion of  enucleation,  or  other  prophylactic  measure,  having  been 
decided   in   one  sense  or  the  other,  the   means  to    be   directed 

*  Leber,  A.  v.  Graefe's  Archiv,  xxvii,  pt.  1,  p.  339. 

t  Archives  of  Ophthalmology,  xiv,  p.  223. 

1  By  F.  R.  Cross,  Proceed.  Ophthal.  Soc,  July,  1887. 


SYiAFPATHETIC    OPHTHALMITIS.  267 

against  the  process  in  the  sympathizing  eye  have  to  be  consid- 
ered. The  patient  should  be  confined  for  a  lengthened  period 
to  a  dark  room  and  atropine  used  for  the  eye,  while  the 
general  system  is  maintained  by  a  touic  but  non-stimulating 
treatment.  It  is  doubtful  whether  other  means  are  of  much 
value.  Mercurialization  is  employed  by  some  surgeons  in  these 
cases,  but  its  value  is  problematical. 

No  operation  should  be  undertaken  for  the  formation  of  an 
artificial  pupil  in  the  sympathizing  eye  until  the  inflammatory 
process  has  completely  subsided,  the  tension  of  the  eye  improved, 
and  the  vascularity  of  the  iris  diminished.  This  period  is, 
at  the  least,  from  twelve  to  eighteen  months  after  the 
onset  of  the  disease.  If  operative  interference  be  resorted 
to  during  that  period,  the  result  is  an  aggravation,  or  rekind- 
ling, of  the  inflammation,  with  closure  of  the  artificial  pupil 
which  may  have  been  made,  in  consequence  of  proliferation  of 
the  layer  of  retro-iritic  connective  tissue.  Not  even  if  the 
eyeball  become  of  glaucomatous  hardness,  as  sometimes  happens, 
should  the  surgeon  be  tempted  to  operate.  This  is  a  golden 
rule. 

Of  the  operations  employed  for  the  establishment  of  an  arti- 
ficial pupil  in  an  eye  which  has  suflTered  from  sympathetic 
ophthalmitis  resulting  in  anterior  phthisis,  iridectomy  most 
naturally  suggests  itself  and  is  the  least  satisfactory.  The 
reason  of  this  is  that,  owing  to  its  very  disorganized  state, 
the  iris  tears  when  drawn  on  by  the  forceps  ;  and,  hence,  the 
formation  of  a  satisfactory  coloboma  is  almost  impossible,  and 
even  if  this  be  obtained  it  is  extremely  liable  to  close  again 
from  proliferation  of  the  retro-iritic  connective  tissue  set  going 
anew  by  the  irritation  of  the  operation.  Yet  sometimes,  after 
repeated  iridectomies,  a  permanently  clear  pupil  is  obtained. 

Von  Graefe  operated  by  making  a  peripheral  linear  incision 
as  for  cataract,  but  passed  the  knife  behind  the  iris,  and  in 
doing  so  he  opened  the  capsule  of  the  lens.  An  iridectomy 
is  then  made  by  seizing  a  wide  portion  of  the  iris  and  corre- 
sponding retro-iritic  connective  tissue   with  a  special  forceps, 


2()8  DISEASES   OF   THE   EYE. 

one  blade  of  which  is  passed  behind  these  structures,  whilst  the 
other  enters  the  anterior  chamber,  and'  then  the  iris,  etc.,  having 
been  drawn  out,  the  exposed  portion  is  cut  off.  The  partially, 
or  completely,  opaque  lens,  or  a  considerable  portion  of  it, 
becomes  evacuated  during  this  proceeding;  or,  if  not,  the  usual 
measures  are  taken  to  extract  it.  With  this  method,  also,  the 
pupil  frequently  closes  again,  and  even  more  than  one  supplemen- 
tary iridectomy,  or  iridotomy,  may  be  required,  but  must  not  be 
undertaken  until  all  irritation  subsides.  The  iridectomy,  as 
above  described,  is  now  with  advantage  often  replaced  by  a 
V  shaped  one,  made  with  de  Wecker's  forceps-scissors. 

The  late  Mr.  George  Critchett's  Method  for  the  formation  of 
a  pupil  in  these  cases  consists  in  passing  a  discission  needle,  by  a 
boring  motion,  through  the  lenticular  capsule ;  another  needle 
is  passed  in  close  to  the  first,  and  then  by  separating  one  point 
from  the  other  a  rent  is  made  in  the  centre.  This  is  followed, 
generally,  by  the  escape  into  the  anterior  chamber  of  a  small 
quantity  of  cheesy  lens  matter.  The  latter  is  allowed  to  become 
gradually  absorbed,  and  in  the  course  of  some  wrecks  the  capsule 
closes  again.  The  operation  has  to  be  repeated  several  times 
before  a  clear  pupil  is  obtained,  care  being  taken  that  all  irri- 
tation from  the  previous  operation  has  subsided  before  another 
is  undertaken. 

Mode  of  Performing  Enucleation  of  the  Eyeball. — There  are 
two  chief  methods : — 

1.  Bonnet's  Method.  An  incision  is  made  in  the  conjunctiva 
all  round  the  cornea  and  about  6  mm.  removed  from  the  latter. 
The  bulbar  conjunctiva  is  separated  from  the  globe  freely  in  all 
directions  with  a  scissors.  With  a  strabismus  hook  each  orbital 
muscle  is  caught  up,  and  its  tendon  divided  close  to  the  sclero- 
tic. The  globe  can  now  often  be  dislocated  forward  by  pressure 
of  the  margins  of  the  lids  backward,  and  is  then  held  in  the 
fingers  of  the  left  hand,  while  the  optic  nerve  is  divided  with  a 
strong  scissors  passed  into  the  orbit  from  the  median  side.  If 
the  globe  cannot  be  dislocated,  it  may  be  drawn  forw^ard  with  a 
strong  toothed  forceps  while  the  nerve  is  being  divided. 


SYMPATHETIC    OPHTHALMITIS.  269 

2,  The  Vienna  Method.  The  only  instruments  used  in  this 
operation  are  a  strong,  straight  scissors,  and  a  strong  toothed 
forceps.  The  tendon  of  the  internal  rectus  at  its  insertion,  with 
the  overlying  conjunctiva,  is  seized  in  one  grasp  with  the  forceps, 
and  so  held  until  the  conclusion  of  the  operation.  Immediately 
behind  the  forceps  the  tendon  is  divided  with  the  scissors ;  and 
now  the  forceps  is  holding  merely  the  stump  of  the  tendon  ad- 
herent to  the  globe.  Through  the  opening  necessarily  made  at  the 
same  time  in  the  conjunctiva  one  blade  of  the  scissors  is  passed, 
and  pushed  on  under  the  tendon  of  the  inferior  rectus  muscle, 
which  is  then  divided  along  with  the  overlying  conjunctiva.  In 
the  same  way  the  superior  rectus  is  divided.  The  globe  is  now 
drawn  well  forward  and  rotated  outward,  the  scissors  passed 
into  the  orbit,  the  optic  nerve  felt  for,  and  divided.  With  one 
or  two  strokes  of  the  scissors  the  external  rectus  and  the  two 
obliques  are  divided  close  to  the  globe,  and  the  operation  is 
completed.  This  method  is  very  rapid.  It  is  not  suited  to 
any  globe  of  which  the  walls  are  weak  (fresh  perforating  injury, 
extreme  staphyloma,  etc.),  for  a  good  deal  of  pressure  is  exer- 
cised on  the  eyeball  during  its  performance. 

Careful  antiseptic  precautions  are  to  be  employed  in  connec- 
tion with  enucleation  of  the  globe.  Of  these,  I  think,  the  most 
important  is  the  use  of  a  full  stream  of  corrosive  sublimate 
solution  (1  in  5000)  into  the  cavity  of  the  orbit  as  soon  as  the 
eyeball  is  removed,  the  irrigation  being  maintained  for  several 
minutes.  The  interior  of  the  orbit  is  to  be  then  well  covered 
with  finely  powdered  iodoform,  a  piece  of  drainage  tube  placed 
in  the  outer  canthus,  so  as  to  insure  exit  of  any  discharge  which 
may  form,  and  a  wood-wool  or  other  antiseptic  pad  applied  with 
a  bandage.  The  orbit  should  be  similarly  dressed  every  twenty- 
four  hours. 

I  have  never  seen  the  slightest  trouble  after  enucleation  of 
the  eyeball,  but  some  cases  of  meningitis  following  upon  the 
operation,  and  which  have  proved  fatal,  are  reported.  There 
can  be  no  reasonable  doubt  but  that,  in  these  instances,  septic 


270  DISEASES   OF   THE    EYE. 

matter  made  its  way  along  the  lymphatics  of  the  optic  nerve 
to  the  meninges,  and  that  this  septic  matter  was  introduced 
upon  the  instruments,  or  escaped,  in  purulent  cases,  from  the 
interior  of  the  eyeball.  Hence,  the  very  great  importance  of 
the  careful  antiseptic  precautions  above  indicated. 

Occasionally,  in  ten  days  or  longer  after  the  operation,  a 
granulation  forms  in  the  apex  of  the  orbit  and  requires  to  be 
snipped  off.  To  prevent  this  some  surgeons  unite  the  conjunc- 
tival opening  with  a  suture  after  the  eyeball  has  been  removed. 

An  artificial  eye  can  usually  be  inserted  after  a  fortnight,  but 
should  not  be  constantly  worn  for  a  month  at  least;  as,  until 
that  period  elapses,  it  is  liable  to  cause  irritation  and  conjunc- 
tivitis. 

Mode  of  Performing  Resection  of  the  Optic  Nerve. — An  opening 
is  made  into  the  conjunctiva  about  3  mm.  behind  the  insertion 
of  the  internal  rectus  muscle ;  this  muscle  is  laid  bare,  and  two 
curved  blunt  strabismus  hooks  are  inserted  beneath  it.  The 
hooks  are  drawn  in  opposite  directions,  so  that  one  is  caught  in 
the  angle  of  insertion  of  the  tendon  with  a  tendency  to  roll  the 
eye  outward,  while  the  other  will  draw  the  muscle  forward  out 
of  the  orbit.  Near  the  latter  hook  a  catgut  thread  is  passed 
through  muscle  and  conjunctiva,  first  from  within  outward, 
and  then  the  opposite  way.  The  muscle  is  now  divided  at  a 
distance  of  at  least  5  mm.  from  its  insertion  into  the  sclerotic, 
and  the  ends  of  the  catgut  thread  are  tied  in  a  knot.  A  second 
thread  is  passed  through  the  terminal  stump  of  the  muscle  and 
similarly  tied  in  a  knot.  The  wound  is  now  extended  both 
toward  the  superior  and  inferior  recti  muscles,  and  a  small, 
pointed,  double  hook  is  inserted  into  the  sclerotic  far  back,  in 
order  to  draw  the  globe  forward  and  outward.  A  pair  of 
scissors  curved  on  the  flat  are  inserted  alongside  the  globe,  and 
the  optic  nerve  cut  through  as  near  the  optic  foramen  as  pos- 
sible. The  posterior  aspect  of  the  globe  can  now  be  exposed  to 
view  by  means  of  the  double  hook.  The  stump  of  the  optic 
nerve  remaining  on  the  eyeball  is  then  cut  off  near  its  insertion 


SYMPATHETIC   OPHTHALMITIS.  271 

into  the  sclerotic,  the  insertion  of  the  oblique  muscles  divided, 
and  the  whole  of  the  posterior  circumference  of  the  sclerotic 
bared  by  dissection.  The  eyeball  is  replaced,  the  wound  closed 
by  means  of  the  catgut  threads  previously  introduced,  and,  as  a 
precaution  against  sanguineous  exophthalmos,  the  eyelids  are 
united  by  three  sutures. 


CHAPTER  XI. 

THE  MOTIONS   OP   THE   PUPIL   IN   HEALTH  AND 
DISEASE. 

The  Size  of  the  Pupil  in  Health  depends  chiefly  on  the  intensity  of 
the  light  to  which  the  eye  is  exposed,  contracting  when  light  falls  into  the 
eye  and  dilating  in  the  shade.  However  defective  vision  may  be,  if 
quantitative  perception  of  light  remains,  the  reaction  of  the  pupil,  as  a 
rule,  takes  place. 

There  is  no  absolute  Standard  for  the  Physiological  Size  of  the  Pupil. 
The  latter  varies  in  diflferent  healthy  individuals,  being  in  general  smaller 
in  elderly  people  than  in  youthful  subjects,  for  with  increasing  age  the 
energy  of  the  sympathetic — the  dilating  nerve  of  the  iris — is  reduced, 
while  there  is  sclerosis  of  the  walls  of  the  vessels  of  the  iris  and  rigidity 
of  its  stroma.  Persons  with  blue  irides  have,  in  general,  smaller  pupils 
than  those  with  dark  eyes,  for  in  them  more  light  reaches  the  retina,  and 
hence  the  pupil-reflex  is  stronger.  It  has  also  been  stated  that  hyperme- 
tropic eyes  are  apt  to  have  small  pupils,  owing  to  the  constant  effort  of 
accommodation,  while  in  myopia,  for  the  converse  reason,  the  pupils  are 
said  to  be  wide  ;  but  the  observation  is  not  generally  accepted.  The 
diameter  of  the  pupil,  when  the  accommodation  is  at  rest,  has  been 
found*  to  vary  between  2.44  and  5.82  mm.,  giving  an  average  diameter 
of  4.14  mm. 

Contraction  of  the  Pupil. — Contraction  to  light  is  a  reflex  motion,  the 
optic  nerve  being  the  afferent  nerve,  and  the  third  nerve  the  efferent 
nerve  innervating  the  sphincter  pupillae.  It  has  been  shown  by  a  high 
authority  f  that  there  are  special  afferent  fibres  in  the  optic  nerve  for  the 
pupil-reflex,  distinct  from  those  for  vision,  and  that  it  is  possible  to  dis- 
tinguish with  the  microscope  these  two  kinds  of  nerve  fibres  from  each 
other. 

The  anatomical  investigations  of  Meynert+  have  shown  that  between 

*Woinow,  "  Ophthalmometrie,"  Vienna,  1871. 

t  B.  von  Gudden,  Sitznuysher.  d.  Munch. Ges.  f.  Morphof.  it.  Phi/sioL,  1886,  i,  p.  1. 

:j:  Voin  Gehirn  der  Siiugethiere,  "Strieker's  Handbuch,"  Leipzig,  1870. 

272 


THE   PUPIL   IN    HEALTH    AND    DISEASE. 


273 


Fig.  101, 


the  corpora  quadrigemina  and  the  centre  for  the  third  nerve  run  commu- 
nicating fibres  (2,  Fig.  101),  which  probably  enable  this  reflex  to  take 
place.  Owing  to  the  semi -decussation  of  the  fibres  in  the  optic  chiasma, 
the  stimulus  of  light,  when  applied  to  one  eye  alone,  passes  up  each  tract 
with  equal  power  to  the  corpora  quadrigemina,  and  thence  by  Meynert's 
fibres  to  the  centre  for  the  third  nerve  (or  rather  to  that  portion  of  it 
which  acts  as  a  special  centre 
for  the  sphincter  pupillae),  and 
from  that  point  down  the  my- 
otic, or  short  ciliary,  branches 
of  this  nerve  to  each  ciliary 
ganglion,  the  ciliary  nerves, 
and  each  sphincter  iridis,  caus- 
ing as  active  a  contraction  of 
the  pupil  in  the  non-illumi- 
nated eye  (consensual  con- 
traction) as  in  its  fellow.  It 
is  probable, however,*  that,  in 
addition  to  this  method  of 
bringing  about  consensual 
contraction  of  the  pupil,  there 
is  a  communication,  direct  or 
indirect,  between  the  centres 
for  the  third  nerve  of  each  side 
capable  of  effecting  it."^  In  no 
other  way  can  the  fact  be  ex- 
plained, that  consensual  con- 
traction of  the  pupil  is  main- 
tained, in  cases  of  homony- 
mous   hemianopsia.     If,    for 

instance  (Fig.  101),  there  be  a  lesion  of  the  right  tractus  opticus  giving 
rise  to  left  hemianopsia,  the  centre  of  the  left  third  nerve  alone  can  be 
primarily  stimulated  ;  but,  as  both  pupils  act,  a  communication  between 
the  centres  of  the  third  nerves  must  exist.  Merkel  t  believes  that  there 
is  a  direct  anastomosis  between  these  centres. 

But  it  must  be  stated  that  there  is  a  good  deal  of  divergence  of  opinion 
as  to  the  path  by  which  the  pupil-reflex  is  brought  about.     Bechterew  is 


N.  Centre  of  third  nerve.  1.  Connection  be- 
tween nuclei  of  third  nerves.  2.  Meynert's 
fibres.  Q.  Corpora  quadrigemina.  C.  Chiasma. 
0.  Optic  nerve.  P.  Myotic  fibres  of  third  nerve. 
L.  Seat  of  Lesion.  Arrows  show  path  of  im- 
pulse in  lesion  of  right  tract  at  L. 


*  Lesser,  "  Die  Pupillarbewegung  ir 
iehung,"  Weisbaden,  1881,  p.  U. 
■f-  Grnefe-Siemisch  Handbuch,  vol.  i. 


Physiologischer  und  Pathologiseher  Be- 


274  DISEASES   OF   THE   EYE. 

of  opinion  that  the  centripetal  pupillary  fibres  pass  uncrossed  from  the 
chiasma  directly  to  the  gray  matter  surrounding  the  third  ventricle,  and 
thence  backward  to  the  pupillary  nucleus  of  the  oculo- motor  nerve  of  their 
own  sides  respectively.  Gudden  made  experiments  which  seemed  to  him 
to  prove  that  the  corpora  quadrigemina  had  nothing  to  do  with  this  path, 
and  ascribed  to  the  external  geniculate  body  the  part  usually  assigned  to 
the  corpora  quadrigemina.  Mendel's  experiments  ^  would  lead  to  the 
view  that  it  is  the  ganglion  habenulge  which  is  the  centre  for  the  pupillary 
reflex  in  animals,  and  in  this  he  is  largely  supported  by  Darkschewitz, 
who  holds  that  the  pupillary  fibres  from  the  optic  tract  pass  both  into  the 
pineal  gland  and  the  ganglion  habenulae.  According  to  Mendel  the  reflex 
path  would  be:  Optic  nerve,  optic  tract,  to  the  ganglion  habenulse  of 
the  same  side,  thence  by  the  posterior  commissure  to  the  nucleus  of  the 
third  nerve,  and  thence  to  the  ciliary  nerves. 

The  reflex  mobility  of  the  pupil  to  light  is  tested,  most  commonly,  for 
the  purpose  of  deciding  the  existence,  or  otherwise,  of  posterior  synechiae. 
The  next  most  common  object  of  the  test,  and  the  one  with  which  we 
are  here  concerned,  is  to  determine  the  sensitiveness  to  light  of  the 
retina,  or  of  the  visual  centre.  It  affords,  generally,  a  sufficient  test  of 
the  presence  or  absence  of  quantitative  perception  of  light;  but  it  must 
be  remembered  that  the  latter  function  may  be  wanting  in  certain 
diseased  states  and  yet  the  pupil-reflex  take  place,  or  the  pupil-reflex 
may  be  wanting  and  still  perception  of  light  be  present.  The  test  is 
best  performed  in  diffuse  daylight,  with  the  patient's  face  directed 
toward  the  window,  a  distant  object  being  looked  at,  and  the  eye  which 
is  not  under  examination  being  carefully  excluded  from  the  light.  The 
surgeon  then,  having  observed  the  size  of  the  pupil  to  be  examined, 
excludes  the  eye  from  light  with  his  hand  for  some  moments.  On 
removing  the  excluding  hand,  a  normally  reacting  pupil  will  be  found 
to  have  become  dilated ;  and  this  dilatation,  after  an  interval  of  about 
half  a  second,  will  be  observed  to  give  way  to  an  extreme  contraction, 
which  is  maintained  only  for  a  moment,  and  is  then  succeeded  by  a 
moderate  dilatation,  and  the  pupil  then  again  contracts  somewhat,  and 
80  on,  until,  after  some  further  minute  oscillations,  it  comes  to  a  stand- 
still. The  explanation  for  this  phenomenon — which  is  termed  Hippus — 
is,  that  each  contraction  of  the  pupil,  by  diminishing  the  supply  of  light 
to  the  retina,  contains  in  itself  the  cause  of  the  succeeding  dilatation  ; 
and,  for  the  converse  reason,  each  dilatation  sets  agoing  the  succeeding 
contraction,  until  at  last  equilibrium  is  attained.  A  comparison  between 
the  maximum  of  dilatation  and  maximum  of  contraction,  along  with  the 

'^Nexiroloy.  Centntlbf.,  1890,  p.  184. 


THE    PUPIL    IN    HEALTH    AND    DISEASE.  275 

promptness  and  rapidity  with  which  the  contraction  takes  place,  enables 
the  observer  to  form  an  estimate  of  the  activity  of  the  pupil-reflex.  In 
performing  this  test,  it  is  important  that  the  patient's  gaze  should  be 
fixed  all  through  on  a  distant  object — hence,  unless  where  a  mere  trace 
of  perception  of  light  remains,  the  test  used  with  the  artificial  light  is 
not  so  reliable  as  that  with  daylight — so  that  the  pupil-contraction,  which 
is  associated  with  convergence  or  accommodation  {vide  infra),  may  not 
vitiate  the  experiment.  The  danger  of  a  vitiation  of  the  experiment  by 
the  reflex  dilatation  from  the  skin  {vide  infra),  caused  by  the  excluding 
hand,  is  insignificant  in  practice.  The  consensual  reflex  of  the  pupil,  as 
well  as  the  direct,  should  always  be  tested  ;  one  eye  being  alternately 
excluded  and  exposed,  the  motions  of  the  pupil  of  the  other  eye  are 
observed  and  compared  with  those  of  its  fellow.  In  examining  the 
pupils  we  have  also  to  decide  whether  they  be  of  equal  size  ;  and,  in 
order  to  avoid  error  through  posterior  synechias,  the  comparison  should 
be  made,  with  both  eyes  open,  successively  in  two  very  different  bright- 
nesses of  light.  Under  normal  conditions  equality  in  size  of  the  pupils 
will  exist,  not  only  with  both  eyes  open,  but  also  if  one  eye  be  shaded ; 
for  the  normal  consensual  pupil-reflex  is  equal  to  the  direct  reflex.  If 
the  pupils  be  found  of  different  sizes,  the  least  movable  one  is  usually 
the  pathological  pupil,  but  this  question  is  often  dilBcult  to  decide. 
Finally,  it  should  be  noted  whether  the  direct  pupil-reflex  is  similar  in 
all  respects  in  each  eye. 

In  addition  to  the  stimulus  of  light,  the  pupil- contracting  centre  is 
excited  by,  or  simultaneously  with,  the  effort  of  accommodation  for  near 
vision.  The  object  of  this  contraction  is  to  cut  off  rays  falling  on  the 
peripheral  portions  of  the  lens,  which  latter  are  not  curved  in  the  change 
for  accommodation  to  the  same  degree  as  is  the  centre  of  the  lens.  This 
contraction,  however,  is  much  more  intimately  connected  with  conver- 
gence of  the  visual  lines  than  with  the  effort  of  accommodation.  It 
has  been  shown*  that  the  contraction  increases  with  the  effort  of 
accommodation,  but  not  proportionately  to  the  distance  of  the  fixation 
point  from  the  eye ;  andf  that  the  pupils  do  not  contract  if  accommo- 
dation be  effected  without  convergence  ;  but  that  in  convergence  without 
accommodation  contraction  is  observed.  It  has  also  been  found  that 
the  contraction  was  proportional  to  the  degree  of  convergence,  and  that 
in  myopes  of  high  degree  contraction  of  the  pupil  takes  place  at  the  other 
side  of  the  far  point,  where,  of  course,  the  accommodation  does  not  come 


*  Adamiik  and  Woinow,  Archiv  fur  Ophthalinologle,  xvii,  pt.  1 
IE.  H.  Weber,  "De  Motu  iridis,"  Lipsiae,  1851. 


276  DISEASES    OF    THE    EYE. 

into  play.  Aubert  *  thinks  there  is  probably  a  common  centre  for  the 
three  actions — convergence,  accommodation,  and  pupil-contraction — a 
view  supported  by  Priestley  Smith  f;  and  Henson  and  Viilckers  J  have 
found  that  in  dogs,  in  the  posterior  part  of  the  floor  of  the  third  ventricle, 
the  centres  for  the  branches  to  the  ciliary  muscle,  the  sphincter  pupillae, 
and  the  rectus  internus  occur  in  close  succession,  and  they  think  that 
this  region  may  be  regarded  as  the  centre  assumed  by  Aubert.  The 
existence  of  such  a  centre  has  been  placed  beyond  controversy  by 
Eales's  case|  of  paralysis  of  convergence  and  accommodation,  and  of 
the  associated  pupillary  contraction.  These  three  motions,  then,  are  not 
dependent  on  each  other,  but  are  co-effects  of  one  and  the  same  cause, 
i.  e  ,  a  stimulus  applied  to  the  centre  for  convergence,  accommodation, 
and  pupil-contraction. 

In  examining  the  mobility  of  the  pupils  in  a  given  case,  the  contrac- 
tion on  convergence  should  not  be  omitted.  If  the  patient  be  blind  of 
both  eyes,  the  observation  can  be  made  by  calling  on  him  to  direct  his 
eyes  toward  his  own  hand  at  about  twelve  inches  distance.  If  both 
accommodative  contraction  and  light  reflex  are  wanting,  a  lesion  in  the 
course  of  the  centrifugal  pupil  fibres  is  indicated,  while  if  the  light 
reaction  alone  is  wanting,  the  lesion  is  in  the  course  of  the  centripetal 
fibres. 

Dilatation  of  the  Pupil. — The  most  reliable  investigations  ||  have  dis- 
tinctly proved  that  there  is  no  such  muscle  as  the  dilator  pupillae.  The 
dilatation  of  the  pupil  is,  in  all  probability,  largely  the  result  of  an 
inhibitory  action  of  the  sympathetic,  a  view  maintained  also  by  Gaskell^ 
and  Jessop.*"^  The  posterior  limiting  membrane  of  the  iris  is  its  only 
structure  which  is  not  thrown  into  folds  when  the  pupil  dilates  (Fuchs), 
and  therefore  there  can  be  little  doubt  but  that  it  takes  an  active  part  in 
dilating  the  pupil,  probably  by  reason  of  its  elasticity.  Yet,  inasmuch 
as  when  the  pupil  is  dilated  from  paralysis  of  the  third  nerve  a  further 
dilatation  can  be  produced  by  atropine,  it  is  probable  that  some  other  as 
yet  unascertained  dilating  power  resides  in  the  iris.  The  mydriatic  err 
long  ciliary  nerves,  originating  (Henson  and  Viilckers)  in  the  front  part 

*"Graefe  und  Saemisch  Handbuch,"  ii,  p.  669. 

t  Ophthal.  Hasp.  Rep.,  Vol.  ix,  p.  32. 

\  Arch  f.  Ophthal.,  xxiv,  pt.  1,  p.  23. 

^  Tvana.  Ophthd.  Soc,  .Jan.  10,  1884. 

II  Schwalbe,  "  Handbuch  der  Sinnesorgane  :"  Eversbiisch.,  "  Berit-ht  d.  Ophthal 
Gesellsch.,"  1884;  Fuchs,  (irtte/e's  Archiv,  xxxi,  pt.  3,  p.  39;  Jessop,  Proceed. 
Roy.  Soc,  1886,  p.  478. 

^  Journ.  of  PhrjH.,  vii,  1,  p.  38.  "^  Proceed.  Roy.  Soc.,  1886,  p.  484. 


THE    PUPIL    IX    HEALTH    AND    DISEASE.  277 

of  the  floor  of  the  aqueduct  of  Sylvius,  pass  to  a  region  in  the  lower 
cervical  and  upper  dorsal  portion  of  the  cord,  called  by  Budge*  the 
ciliospinal  centre,  and  from  thence  pass  out  with  the  two  first  dorsal 
nerves,  and  by  way  of  the  rami  communicates,  to  the  sympathetic  in  the 
neck,  and  thence  to  the  cavernous  plexus,  gasserian  ganglion,  ophthalmic 
division  of  the  fifth  nerve,  nasal  branch  of  this  division,  ganglionic  branch 
of  this  nerve,  ciliary  ganglion,  there  joined  by  more  branches  from  the 
cavernous  plexus,  and  from  thence  by  the  short  ciliary  nerves  reach  the 
eye. 

The  dilating  nerve  fibres  are  probably  of  twofold  nature,  muscular  and 
vasomotor.  The  experiments  of  Grunhagen,t  Salkowski,i  Bonders, 
and  Hamer, I  Stellwag,  'I  and  F.  Arlt,  Jr.,*"  indicate  this,  and  that  the 
centre  for  each  kind  of  fibre  is  different,  though  both  are  situated  in  the 
medulla  oblongata,  and  their  fibres  probably  run  the  same  course  to  the 
eye.  The  centre  for  the  muscular  fibres  is  called  the  oculo-pupillary 
centre.  That  the  vasomotor  fibres  have  a  decided  and  independent 
influence  in  dilating  the  pupil  has  been  shown  by  Rouget,  *^  Schoeler,tt 
and  others.  It  is  not  certain  what  the  mechanism  of  this  influence  may 
be,  but  it  probably  consists  in  a  diminution  in  volume  of  the  iris,  from 
antemia  caused  by  contraction  of  the  muscular  coat  of  the  vessels. 

While  light  is  the  only  stimulus  capable  of  bringing  about  a  reflex 
contraction  of  the  pupil,  the  pupil-dilating  centre  reacts  to  every 
sensitive  stimulus,  e.  g.,  the  prick  of  a  pin  or  a  pinch  on  the  neck, 
galvanism  applied  to  the  leg,  ji  the  tickling  of  a  sensitive  place  in  the 
region  of  the  fifth  nerve  on  the  face,  Vi  etc.,  and  Westphal  !;||  observed 
dilatation  on  shouting  loudly  into  the  ear  of  a  person  under  chloroform. 
Schiff  and  Foa  *^^  found  that  in  curarized  dogs  and  cats  a  dilatation  took 
place  on  the  application  of  every  stimulus,  not  necessarily  painful, 
applied  to  the  nerves  of  common  sensation  in  any  part  of  the  body. 
The  centre  for  this  reflex  is  probably  in  the  medulla  oblongata,***  but 


*  "Ueber die  Bewegungen  der  Iris,"  1S55,  -f  Zeitschriftf.  rat.  Med.,  xxviii. 

Xlhid.,  xxix,  p.  167.  I  Xederl.  Tijaschr.  v.  Geneesh,  1864. 

Ij  "Ueber  Atropin,"  All.  Wiener  Med.  Zeitung,  1872,  p.  146. 

^^  ArcTiiv.filr  OphthaL,  xv,  i. 

^^"  Comptes  rendus  et  Mem.  de  la  Soe.  de  Biologic,"  1856. 

ft  "  Experimentelle  Beitrage  zur  Irisbewegung  :  "  Inaug.  Diis.  Doipat.  1869. 

j j  Arndt,  Griesengera  Archiv  f.  Psych.,  ii. 

|§  Hecker,  "  Tageblatt  der  45  Versam.  deutscher  Xaturforscher  in  Leipzig,"  1872. 

{Ill   Virchnic's  Archie,  xxvii,  p.  409. 

^■[  "  La  pupilla  come  estesiometro."     L'Imparziale,  1874. 

^5^**  Salkowski,  loc.  cit. 


278  DISEASES   OF   THE    EYE. 

inasmuch  as  it  takes  place  if  the  cervical  sympathetic  be  divided,*  it  is 
evident  that  all  the  dilating  fibres  do  not  run  to  the  eye  by  way  of  the 
cervical  sympathetic.  Schiff,  f  indeed,  thinks  it  probable  that  the 
gasserian  ganglion  receives  pupil-dilating  fibres  from  the  sympathetic 
traversing  the  cavum  tympani. 

Some  psychical  emotions  produce  dilatation  of  the  pupil.  The  pupils 
of  a  cat  in  anger  dilate,  and  those  of  a  frightened  child.  In  sleep,  or 
when  under  the  complete  influence  of  an  anaesthetic,  the  pupils  are 
contracted,  for  then  all  psychical  and  sensitive  stimuli  are  reduced  to  a 
minimum.  Facts  authorize  the  conclusion  that  the  medium  dilatation  of 
the  pupil  in  the  healthy  state  depends  chiefly  on  the  intensity  of  these 
stimuli,  habitually  transmitted  through  the  sympathetic.  If  in  any  indi- 
vidual they  be  slight,  his  pupil  is  contracted ;  if  intense,  it  is  dilated. 
Arndt  j  asserts  that  in  delicate,  nervous,  excitable  people  the  pupils  are 
often  much,  and  habitually,  dilated. 

In  addition  to  those  already  mentioned,  there  are  causes  for  the  dilata- 
tion of  the  pupil  which  can  hardly  be  referred  to  simple  reflex  action,  but 
which  seem  to  be,  like  the  contraction  of  the  pupil  on  convergence  of  the 
visual  lines,  associated  with  those  of  other  centres  in  the  medulla 
oblongata,  especially  with  those  for  respiration  and  uterine  action.  With 
every  deep  inspiration  or  expiration  a  considerable  pupillary  dilatation 
takes  place,  not  identical  with  that  slight  dilatation  occurring  on  each 
ordinary  inspiration,  and  depending  on  variation  of  blood  pressure,  but 
due^  to  simultaneous  stimulation  of  the  respiratory  and  pupil-dilating 
centres,  by  retention  of  carbonic  acid  gas  in  the  blood.  Raehlmann  and 
Witowski||  have  observed  marked  dilatation  at  the  beginning  of  each 
labor  pain,  to  be  explained  as  an  associated  action  of  the  neighboring 
centres  for  uterine  movements  and  pupil-dilatation. 

Besides  the  normal  pupillary  motions  described  in  the  foregoing,  and 
visible  for  the  most  part  to  the  naked  eye  of  the  observer,  there  is  a 
phenomenon  of  pupillary  motion  which  is  discoverable  only  by  aid  of  a 
corneal  microscope  or  loup,  consisting  in  perpetual,  but  very  minute  and 
irregular,  fluctuations  in  size  of  the  pupil.  This  hippus  has  been  aptly 
termed  by  Laqueur*y  the  Unrest  of  the  Pupil,  and  is  due  to  the  ever  vary- 
ing sensitive  and  psychical  reflexes,  which  are  thus  constantly  manifesting 
their  influences  on  the  pupil. 

*Vuljjiaii,  Archiv  de  ji^y^iol.,  etc.,  de  Brown- Sequard.     Janvier,  1874. 

t ''  Unteisuchungen  zur  Naturlehre,"  x,  1867,  p.  423. 

J  Archiv/.  Psychiatrie,  ii,  p.  589. 

^  SchiflF,  loc.  cit.  tl  Archiv  f.  Physiolofjie,  1878,  p.  110. 

^,  Klin.  Monatxhl.f.  Aiiyeuhtilk.,  Dec,  1887. 


THE    PUPIL    IN    HEALTH    AND    DISEASE.  279 

The  Fifth  Nerve  has  been  held  by  some  to  have  an  influence  over  the 
motions  of  the  iris  similar  to  that  of  the  sympathetic.  This  is  doubtless 
a  mistaken  view,*  the  effect  on  the  pupil  following  section  of  the  fifth 
within  the  cranium  being  due  to  paralysis  of  the  sympathetic  fibres  con- 
tained in  it,  and  not  to  the  lesion  of  the  proper  fibres  of  the  fifth  nerve. 
Others  t  again  have  ascribed  to  the  fifth  nerve  a  direct  influence  over 
the  contraction  of  the  pupil ;  but  this  is  to  be  regarded  as  a  reflex 
action  merely,  Merkel  indeed  having  demonstrated  %  the  existence  of 
a  direct  fibrillar  connection  between  the  centres  of  the  fifth  and  third 
nerves. 

Action  of  the  Mydriatics  on  the  Pupil.  Atropine. — Inasmuch  as  a 
maximum  mydriasis  can  only  result  from  paralysis  of  the  pupillary 
branches  of  the  third  nerve,  combined  with  excitation  of  the  pupillary 
branches  of  the  sympathetic,  and  as  atropine  effects  such  a  mydriasis, 
it  is  evident  that  it  acts  in  the  way  indicated  on  these  nerves.^  A.  von 
Graefe  proved  ||  that  the  aqueous  humor  of  an  eye  into  which  atropine 
has  been  instilled  acts  as  a  mydriatic  when  applied  to  another  eye. 
Duhoisine,  Hyoscy amine ^  and  Daturine  act  similarly  to  atropine.  Co- 
caine mydriasis  seems  1[  to  be  induced  merely  by  a  local  irritation  of  the 
endings  of  the  sympathetic  in  the  iris,  both  of  the  vaso-constrictor  fibres 
and  of  the  pupil  inhibitory  fibres.  Strychnine  and  curare  are  not, 
strictly  speaking,  mydriatics,  as  they  only  indirectly  affect  the  pupil ;  the 
mydriasis  observed  in  poisoning  by  these  drugs  being,  according  to 
Schiff  **  and  others,  the  result  of  the  retention  in  the  blood  of  carbonic 
acid  gas. 

Action  of  the  Myotics  on  the  Pupil.  Eserine  (or  Physostigmine). — 
This  drug  is  in  all  respects  a  complete  antagonist  of  atropine, ff  paralyzing 
the  peripheral  endings  of  the  sympathetic  in  the  iris,  and  stimulating 
the  endings  of  the  branch  of  the  third  nerve  in  the  sphincter  pupillse. 
Pilocarpine  and  Muscarine  act  similarly,  but  not  with  the  same  energy. 
Nicotine,  applied  to  the  eye,  is  found  to  act  like  eserine.  J  J     Morphium 

*"  Leeser,  loc.  cit.,  pp.  46-48. 

I  Griinhagen,  Beil.  Klin.  Wochenschr.,  1866,  No.  24;  Rogow,  ZciUchr.f.  rut. 
Med.,  Vol.  xxix,  p.  289.  %  ''  Graefe  und  SEemiscli's  Harnlbuch,"  i,  p.  14U. 

§  Hermann,  "  Lehrb.  der  exp.  Toxicologic, '•'  1874. 

II  Archiv.f.  OphthaL,  i,  pt.  1,  p.  462,  foot-note. 
%  Jessop,  Proceed.  Roy.  Soc,  p.  441,  1885. 
^"^P/lUger's  Archiv,  1871,  p.  229. 

ttHarnack,  Arch.  f.  exp.  Pathol.,  ii,  p.  307;  A.  Weber,  Archiv  f.  OphthaL, 
xxii,  pt.  2,  p.  231. 

XX  Rogow,  Zeitschrift  f.  rat.  Med.,  xxix,  p.  1 ;  Schur,  Zeituchrift  f.  rat.  Med., 
xxxi,  p.  402. 


280  DISEASES    OF    THE    EYE. 

has  an  antagonistic  effect  to  atropine,  both  as  regards  the  pupil  and  the 
general  nervous  system,  and  is  employed  in  cases  of  poisoning  by  atropine 
{vide  p.  237). 

Chloroform  in  the  first  or  excitation  stage  of  ancesthesia,  according  to 
the  investigations  of  Westphal, "  Budin,t  and  Hirschberg.  J  stimulates  the 
pupil  dilating  centre,  and  in  the  second  stage  gradually  reduces  the  ex- 
citability of  this  centre,  until,  finally,  it  is  completely  paralyzed,  so  that 
no  form  of  stimulation  causes  any  dilatation.  Following  on  this  is  a  still 
further  contraction  to  a  pin-hole  pupil,  due  to  stimulation  of  the  pupil- 
contracting  centre.  Should  the  inhalation  of  the  anaesthetic  be  continued 
longer,  a  dilatation  of  the  pupil,  often  sudden,  takes  place,  and  this 
indicates  paralysis  of  the  pupil  contracting  centre,  and  the  most  serious 
consequences  for  the  life  of  the  patient. 

The  Size  of  the  Pupil  in  Disease. — Myosis  may  be  caused  by  a  dis- 
eased process  irritating  the  pupil-contracting  centre  or  nerve-fibres  (the 
Irritation  Myosis  of  Leeser),  or  by  one  causing  paralysis  of  the  pupil- 
dilating  centre  or  nerve-fibres  (the  Paralytic  Myosis  of  Leeser),  or  by  a 
combination  of  both.  Either  cause  alone  would  produce  a  medium 
myosis ;  a  combination  of  the  two  would  give  a  maximum  myosis. 

Irritation  Myosis,  according  to  Leeser,  is  not  usually  increased  by  the 
stimulus  of  light,  nor  on  convergence  of  the  visual  axes,  nor  does  it 
diminish  in  the  shade.  Mydriatics  dilate  such  a  pupil  widely ;  myotics 
contract  it  ad  maximum.  In  paralytic  myosis  the  pupil  reacts  well  to 
light  and  on  convergence,  but  does  not  dilate  on  application  of  sensitive 
or  psychical  stimuli  or  with  co-ordinated  motions.  Mydriatics  dilate 
such  a  pupil  only  partially,  while  myotics  contract  it  ad  maximum.  In 
maximum  myosis  every  reaction  is  wanting,  strong  mydriatics  alone 
producing  a  medium  dilatation. 

Irritation  myosis  is  found  in :  a.  The  early  stages,  at  least,  of  all  in- 
flammatory affections  of  the  brain  and  its  meninges,  in  simple,  tubercular, 
and  cerebro-spinal  meningitis.  When,  in  these  diseases,  the  medium 
myosis  gives  place  to  mydriasis,  the  change  is  a  serious  prognostic  sign,| 
indicating  the  stage  of  depression  with  paralysis  of  the  third  nerve,  b. 
In  cerebral  apoplexy  the  pupil  is  at  first  contracted,  according  to  Bert- 
hold,  1|  who  points  out  that  this  contraction  is  a  diagnostic  sign  between 
apoplexy  and  embolism,  in  which  latter  the  pupil  is  unaltered,  c.  In  the 
early  stages  of  intra-cranial  tumors  situated  at  the  origin  of  the  third 
nerve  or  in  its   course,     d.  At  the  beginning  of  an  hysterical  or  of  an 

*  Virchntv's  Archiv,  xxvii,  p.  409.       f  Gazette  des  Hopitaux,  1874,  p.  910. 

X  Berl.  Klin.  Wochenschr.,  1876,  p.  652. 

^  Leeser,  loc.  cit.,  p.  82.  ||  Berl.  Klin.  Wochenxchr.,  1869,  No.  .39 


THE    PUPIL    IN    HEALTH    AND    DISEASE.  281 

epileptic  attack.  -  e.  In  tobacco  amblyopia,!  probably  from  stimulation 
of  the  pupil- contracting  centre  by  the  nicotine,  /.  In  persons  following 
certain  trades,  as  the  result  of  long-maintained  effort  of  accommodation  % 
(watchmakers,  jewelers,  etc.),  the  pupil-contracting  centre  being  subject 
to  an  almost  constant  stimulus,  g.  As  a  reflex  action  in  ciliary  neurosis; 
consequently,  in  many  diseased  conditions  of  those  parts  of  the  eye  sup- 
plied by  the  fifth  nerve. 

Paralytic  myosis  occurs  :  In  spinal  lesions  above  the  dorsal  vertebrse, 
e.  g.s  injuries,  and  inflammations,  especially  of  the  chronic  form.  The 
contracted  pupil  occurring  in  gray  degeneration  of  the  posterior  columns 
of  the  spinal  cord  has  been  long  known  as  Spinal  Myosis.  In  the  simple 
form  of  this  myosis  the  pupil  has  but  a  medium  contraction,  and  reacts 
both  to  light  and  on  convergence.  This  condition  is  found  in  the  early 
stages  alone,  when  the  disease  has  attacked  merely  the  cilio-spinal 
centre,  or  higher  up,  as  far  as  the  medulla  oblongata  ;  later  on,  when 
Meynert's  fibres  become  engaged,  we  have  the  Argyll-Robertson  pupil. 
The  very  minute  pupil,  often  seen  in  tabes  dorsalis,  is  probably  due  to 
secondary  contraction  of  the  sphincter  pupilla3.|| 

Argyll-Robertson  was  the  first  to  point  out,*[  that  in  tabes  dorsalis 
the  pupil,  although  contracted,  and  responding  to  light  by  further  con- 
traction but  slightly,  or  not  at  all,  does  become  more  contracted  on 
convergence  of  the  visual  axes  (or  accommodation).  He  explained  this 
phenomenon  as  being  due  to  paralysis  of  the  cilio-spinal  nerves,  which 
he  therefore  regarded  as  the  nerves  supplying  the  sphincter  iridis.  But 
Raehlmann  points  out**  that  the  myosis  and  the  motor  phenomenon  are 
not  directly  connected ;  for  it  sometimes  happens  that  pupils  which  do 
not  react  to  light,  and  do  contract  on  convergence,  are  not  habitually 
contracted,  and  may  even  be  somewhat  dilated.  The  two  symptoms  are, 
no  doubt,  often  present  together  in  tabes.  The  myosis  is  a  sign,  and  an 
important  one,  of  disease  of  the  posterior  columns,  while  the  defective 
reaction  to  light  with  retained  contraction  on  convergence  indicates 
disease  at  some  distance  from  the  spinal  cord,  namely,  in  Meynert's 
fibres ;  and  this  is  probably  the  correct  explanation  of  the  Argyll- 
Robertson  symptom.  Disease  in  Meynert's  fibres,  however  (as  also 
disease  of  the  optic  nerve),  may  be  in  direct  connection  with  disease  of 

*Wecker,  "Graefe  und  Sjeiuisch's  Handbuch,"  iv. 

fHirschler,  Arch./.  Ophthal.,  xviii,  pt.  1. 

^  Seiffert,  Allgem.  Zeitschrift  fiir  Psychieatrie,  x,  185.3,  p.  544. 

Ji  Hempel,  Archiv  f.  Ophthal.,  xxii,  pt.  1. 

^  Edin.  Med.  Journal,  xiv,  1869,  p.  669,  and  xv,  ISrO,  p.  487. 

^^  Loc.  cit.,  p.  7. 

24 


282  DISEASES   OF   THE   EYE. 

the  cord,  Stilling  having  found*  fibres  passing  directly  from  the  optic 
tract  into  the  eras  cerebri. 

Some  authorities  regard  myosis  as  one  of  the  earliest  symptoms  of 
tabes,  while  others  do  not.  Raehlmann  also  thinks  that,  perception 
of  light  being  present,  if  the  pupils  do  not  react  to  light,  while  they  do 
contract  on  convergence,  the  symptom  is  usually  one  of  serious  central 
disease. 

Paralytic  myosis  is  also  found  in  general  paralysis  of  the  insane. 
In  acute  mania  the  pupil  is  usually  much  dilated,  and  when  this 
mydriasis  is  changed  for  myosis,  approaching  general  paralysis  may  be 
prognosticated.!  Myosis,  following  on  irritation  mydriasis,  is  also  found 
in  myelitis  of  the  cervical  portion  of  the  cord.  In  bulbar  paralysis, 
if  paralytic  myosis  occurs,  the  disease  is  probably  complicated  with 
progressive  muscular  atrophy,  or  with  sclerosis  of  the  brain  and  spinal 
cord.i 

Hirschler  states  ^  that  he  has  frequently  noticed  a  contracted  pupil  in 
alcoholic  amblyopia,  due,  probably,  to  an  affection  of  the  medulla 
oblongata,  possibly  fatty  degeneration.  Myosis  may  also  be  due  to 
paralysis  of  the  cervical  sympathetic,  resulting  from  injury,  from  pressure 
of  an  aneurism  of  the  carotid,  innominate,  or  aorta,  or  from  pressure 
of  enlarged  lymphatic  glands.  In  apoplexy  of  the  pons  Varolii  myosis 
is  present,  but  it  is  not  yet  certain  whether  it  is  an  irritation  myosis  ||  or 
a  paralytic  myosis.  *[ 

Mydriasis  may  be  caused  by  a  diseased  process  giving  rise  to  irritation 
of  the  pupil-dilating  centre  or  fibres,  or  by  paralysis  of  the  pupil-con- 
tracting centre  or  fibres. 

The  former  is  termed  Irritation  (or  Spasmodic)  Mydriasis,  and, 
according  to  Leeser,  is  characterized  by  a  moderately  dilated  pupil, 
contracting  somewhat  to  light  and  on  convergence,  but  not  dilating  on 
sensitive  or  psychical  stimuli ;  easily  dilated  ad  maximum  by  mydriatics, 
but  with  difficulty  contracted  ad  maximum  by  myotics.  The  latter  is 
called  Paralytic  Mydriasis,  and  in  it  there  is  a  moderately  dilated  pupil, 
reacting  to  sensitive  and  psychical  stimuli.  The  reaction  to  light  and  on 
convergence  varies  according  to  the  seat  of  the  lesion.  If  the  lesion  lie 
between  the  iris  and  the  pupil-contracting  centre,  the  direct  and  con- 
sensual reaction  to  light  is  wanting,  as  also  the  associated  motion  on 

*  Bei'hujehe/t  zu  Zehender's  Mon(if>ibl!itfer,  xvii,  i)p.  203-207. 

f  Seiffert,  loc.  ctt.  j  Leeser,  luc.  fit.,  \^.  94. 

g  Archivf.  Ophthal.,  xvii,  pt.  1,  p.  229. 

II  Larcher,  "  Pathol,  de  la  protub.  Annulaire,  deux,  tirage,"  p.  54. 

«[  Jiidell,  Berl.  Klin.Wochenach.,  1872,  No.  24, 


THE    PUPIL   IN    HEALTH   AND    DISEASE.  283 

convergence  of  the  visual  lines.  But  if  the  lesion  lie  between  the  retina 
and  the  pupil-contracting  centre,  the  direct  contraction  to  light  is 
wanting,  while  the  consensual  contraction,  and  that  on  convergence,  are 
retained.  In  either  case  the  pupil  can  be  dilated  ad  maximum  by  mydri- 
atics, but  not  contracted  more  than  to  medium  size  by  myotics. 

Irritation  of  the  pupil- dilating  centre  and  paralysis  of  the  pupil-con- 
tracting centre,  existing  simultaneously,  give  rise  to  maximum  mydriasis. 
In  it  there  is  absolute  immobility  to  stimuli  of  all  kinds,  except  to  strong 
myotics,  which  may  bring  the  pupil  back  to  the  normal  size. 

Irritation  Mydriasis  occurs: — a.  In  hyperemia  of  the  cervical  portion 
of  the  spinal  cord  and  in  spinal  meningitis.  5.  In  the  early  stages  of 
new  growths  in  the  cervical  portion  of  the  cord.  c.  In  cases  of  intra- 
cranial tumor  and  other  diseases  causing  high  intracranial  pressure, 
according  to  Raehlmann,  although  Leeser  points  out  that  these  may  also 
give  rise  to  paralytic  mydriasis,  d.  In  the  spinal  irritation  of  chlorotic 
or  anaemic  people,  after  severe  illness,  etc.  e.  As  a  premonitory  sign  of 
tabes  dorsalis.  /.  In  cases  of  intestinal  worms,  owing  to  the  stimulation 
of  the  sensitive  nerves  of  the  bowel,  and  sometimes  in  other  forms  of 
intestinal  irritation,  g.  In  psychical  excitement,  e.  g.,  acute  mania, 
melancholia,  progressive  paralysis  of  the  insane  (often  then  unilateral, 
with  myosis  in  the  other  eye). 

Unilateral  mydriasis  occurring  at  short  intervals,  now  in  one  eye  and 
now  in  the  other,  is,  according  to  von  Graefe,*  a  premonitory  sign  of 
mental  derangement.  Von  Graefe  observed  madness,  in  the  form  of 
manie  des  grandeurs,  to  come  on  some  months  after  the  occurrence  of 
this  symptom. 

Paralytic  Mydriasis  (Iridoplegia)  may  be  due  either  to  a  paralysis  of 
the  pupil-contracting  centre  or  as  the  result  of  the  stimulus  not  being 
conducted  from  the  retina  to  that  centre.  It  may  be  found  under  the 
former  circumstances  :  a.  Sometimes  in  progressive  paralysis,  where  at 
first  there  was  myosis.  b.  In  various  diseased  processes  at  the  base  of 
the  brain  affecting  the  centre  of  the  third  nerve,  c.  In  a  late  stage  of 
thrombosis  of  the  cavernous  sinus,  f  d.  In  orbital  processes  which 
cause  pressure  on  the  ciliary  nerves,  e.  In  glaucoma.  /.  In  cases  of 
intraocular  tumors  which  have  attained  a  certain  size. 

In  paralytic  mydriasis,  due  to  non-transmission  of  the  stimulus  of  light 
to  a  healthy  pupil-contracting  centre  and  nerves,  contraction  of  the  pupil 
will  take  place  only  on  convergence  of  the  visual  lines.  The  same  con- 
dition of  pupil  will  be  found  if  the  lesion  lies  in  the  course  of  Meynert's 

^  Archiv  f.  Ojyhthal,  iii,  pt.  3,  p.  350. 
fKnapp,  Archivf.  OpJithnl.,  xiv,  pt.  1,  p.  220. 


284  DISEASES   OF   THE   EYE. 

fibres,  although  vision  may  be  normal.  If  the  lesion  lie  in  the  centre  of 
vision,  or  in  the  course  of  the  fibres  connecting  this  centre  with  the 
corpora  quadrigemina,  although  absolute  amaurosis  exist,  the  reaction  of 
the  pupil  to  light  will  be  perfect.  Paralytic  mydriasis,  due  to  non-con- 
duction of  light-stimulus,  is  found  in  most  cases  of  optic  atrophy. 

Professor  Damsch  has  noticed*  a  marked  increased  of  the  hippus  of 
the  pupil  in  certain  diseased  states,  namely,  multiple  sclerosis,  acute 
meningitis,  apoplectic  attacks  followed  by  secondary  tremor  and  spasms 
of  the  paralyzed  muscles,  and  in  neurasthenia.  He  is  inclined  to  liken 
the  hippus  in  these  cases  to  the  increase  of  the  tendon  reflexes,  while 
immobility  of  the  pupil  would  be  the  homologue  of  loss  of  tendon-reflex. 
Yet  he  does  not  think  an  exclusively  reflex  origin  for  the  exaggerated 
hippus  can  be  adopted  in  these  cases,  as  it  continues  to  an  abnormal 
degree  even  when  all  reflex  irritation  is  avoided,  and  consequently  he 
concludes  that  an  increase  of  the  physiological  hippus  must  be  included  as 
a  cause. 

*  Neurolog.  CentralbL,  1890,  p.  258. 


CHAPTER  XII. 
GLAUCOMA- 

The  chief,  and  essential,  symptom  of  this  disease  is  Increased 
Intraocular  Tension — increased  hardness  of  the  eyeball — due 
to  over-fullness  of  the  globe. 

There  is  Primary  Glaucoma  and  Secondary  Glaucoma. 

In  primary  glaucoma  the  increased  tension  comes  on  with- 
out any  previous  recognizable  disease  of  the  eye ;  and  it  is 
with  it  we  have  mainly  to-do  in  this  chapter. 

In  secondary  glaucoma,  the  increased  tension  comes  on  in 
consequence  of  obvious  antecedent  disease  in  the  eye. 

Primary  Glaucoma. 

Of  primary  glaucoma,  commonly  called  "  glaucoma,"  there 
are  two  great  kinds:  the  Non-inflammatory,  Non-congestive, 
or  Chronic  Glaucoma ;  and  the  Inflammatory,  Congestive,  or, 
more  or  less,  Acute  Glaucoma.  In  using  the  term  ''  inflam- 
matory "  here,  it  is  not  to  be  supposed  that  acute  glaucoma  is 
an  inflammation  in  the  strict  pathological  sense  of  the  term, 
or,  if  so,  to  but  a  slight  extent.  The  term  is  employed  rather 
on  account  of  some  symptoms  which  are  present  (pain,  red- 
ness of  the  eyeball,  lachrymation),  and  which  we  are  wont  to 
see  with  inflammations  of  the  eye — symptoms  which  are 
wanting  in  chronic  glaucoma. 

Increased     intraocular     tension,    then,     is    the     chief    and 

*  From  yAxivKog,  sea-green.  The  name  was  given  to  the  disease  by  the 
old  writers,  on  account  of  the  greenish  reflection  obtained  from  the  pupil 
in  some  cases.  But  this  greenish  reflection  is  seen  in  other  diseased 
conditions,  and  therefore  is  not  characteristic  of  glaucoma. 

285 


286  DISEASES   OF   THE    EYE. 

essential  symptom  of  glaucoma,  whatever  form  of  it  may 
come  before  us;  although  this  increased  tension  may  not  be 
present  in  the  same  degree,  or  indeed  at  all,  at  every  time. 

If  the  surgeon  place  the  tips  of  his  index  fingers  close 
together  on  a  normal  eyeball,  and  make  gentle  pressure  with 
them  alternately,  he  will  observe  that  the  eyeball  pits  slightly 
on  this  pressure,  and  that  a  sensation  of  fluctuation  is  given 
to  the  fingers.  The  amount  of  this  pitting  or  fluctuation 
varies  according  to  the  degree  to  which  the  eyeball  is  filled 
with  its  humors,  and  also,  to  some  extent,  according  to  the 
thickness  of  the  sclerotic  coat,  and  is  not  precisely  the  same 
in  every  normal  eye.  The  glaucomatous  eyeball  is  felt  to  be 
more  resistant,  to  be  harder,  than  the  normal  globe. 

But  there  are  eyes  which  have  normally  a  low  tension,  i.  e., 
below  the  average  normal  tension  ;  and  others  which  have  a 
tension  somewhat  above  the  average  normal  tension  ;  and,  in 
eyes  of  the  latter  class,  it  is  occasionally  difiScult  to  decide 
whether  or  not  the  tension  is  abnormally  high,  especially  if 
there  happen  to  be  symptoms  which  might  be  due  to  high  ten- 
sion. If  it  be  a  question  of  one  eye  only,  then  a  comparison  of 
its  tension  with  that  of  its  fellow  decides  the  matter,  for  the 
physiological  tension  is  always  the  same  in  each  eye. 

Some  clinical  experience  is  necessary  before  the  surgeon  can 
appreciate  by  palpation  those  degrees  of  tension  which  are  just 
above  or  just  below  the  normal,  and  no  other  method  is  equally 
satisfactory.  Tonometers  have,  indeed,  been  invented  for  the 
purpose,  but  for  ordinary  use  the  educated  fingers  are  to  be 
preferred. 

For  the  purposes  of  clinical  notation.  Sir  W.  Bowman  sug- 
gested some  signs,  which  have  been  very  generally  adopted. 
Normal  tension  he  indicated  by  the  letter  T,  slight  increase  of 
tension  =  T  -f  1,  still  higher  tension  =  T  -f  2,  while  T  -\-  3 
indicates  stony  hardness  of  the  eyeball.  In  the  same  way,  di- 
minished tension  is  T  —  1,  T  —2,  and  T  —  3.  T  +  ?  and 
T  —  ?  indicate  that  it  is  doubtful  whether  the  tension  be  slightly 
above  or  below  the  normal.     But  the  application  of  these  sym- 


GLAUCOMA. 


287 


bols  to  the  varying  degrees  of  tension  depends  very  much  upon 
the  observer.  "T  +  2,"  for  instance,  will  not  always  convey 
precisely  the  same  idea  to  every  surgeon. 

The  other  symptoms  of  glaucoma  are  largely  due  to  the 
increased  tension,  but  in  chronic  glaucoma  there  are  by  no 
means  so  many  symptoms  as  in  acute  glaucoma.  Let  us  now 
discuss  these  two  great  forms  of  primary  glaucoma  separately. 
And  first  as  to  Chronic,  or  Non-Inflammatory,  Glaucoma  (also 
known  as  Simple  Glaucoma,  as  Simple  Chronic  Glaucoma, 
and  as  Chronic  Non- Congestive  Glaucoma). — Sijmj^toms.     The 


Fig.  102  {Ed.  Jaeger). 


iiii,-H 


sc,  Sclerotic ;  eh,  Choroid  ;  r,  Retina;  of,  Optic  nerve;  ca,  Intervaginal  space;  v,  Ex- 
ternal sheath  of  the  optic  nerve;  e,  Excavation  of  the  papilla;  M,  Margin  of  the 
Excavation ;  Ic,  Lamina  cribrosa. 


tension  is  raised.  Sometimes  the  eye  will  be  very  hard  (T  +  2, 
or  more),  and  again  it  may  be  but  slightly  raised  (T  +1). 
Even  in  one  and  the  same  eye  the  tension  usually  varies, 
and  may  be  at  one  time  too  high,  and  at  another  almost, 
or  quite,  normal. 

The  external  appearance  of  the  eye  is  usually  quite  normal, 
and  the  pupil  reacts  well  to  light.  The  anterior  chamber  is 
sometimes  a  little  shallow. 

On  examination  with  the  ophthalmoscope  the  optic  papilla 
is  found  to  be  "  cupped."  The  optic  papilla,  being  the  weakest 
part  of  the  ocular  wall,  is  the  first  place  to  give  way  to  the 


288  DISEASES   OF   THE    EYE. 

high  tension ;  and,  after  a  time,  it  becomes  depressed  or 
cupped,  the  excavation  being  often  deeper  than  the  outer 
surface  of  the  sclerotic,  and  the  lamina  cribrosa  being  pushed 
back  (Fig.  102).  This  cupping  of  the  papilla  is  a  most 
important  sign  of  glaucoma,  and  differs  essentially  in  ap- 
pearance from  the  physiological  cupping  (vide  p.  78),  inasmuch 
as  it  occupies  the  entire  area  of  the  papilla,  and  has  steep,  not 
shelving,  sides.     As  shown  in   Fig.  102,  the  walls  of  the   ex- 

FiG.  103  {Ed.  Jaeger). 


■^ 


a,  Arteries;  v,  Veins ;   k.  Bending  ol  ihe  ve■^>el^  at  margin  of  the  papilla ;  Vp,  Vessels 
on  the  floor  of  the  excavation  ;  z,  Glaucomatous  ring. 

cavation  are  often  hollowed  out,  and  the  ophthalmoscopic 
effect  of  this  is  to  give  to  the  retinal  vessels  the  appearance 
of  being  broken  off  at  the  margin  of  the  papilla  (Fig.  103), 
where  they  pass  around  the  overhanging  edge  of  the  ex- 
cavation and  become  hidden  by  it,  while  on  the  floor  of  the 
excavation  they  reappear.    .^ 

The  presence  of  an  excavation  may  be  recognized  ophthalmo- 
scopically  in  the  examination  by  the  indirect  method,  by  means 


GLAUCOMA.  289 

of  lateral  motions  of  the  convex  lens.  It  will  be  then  seen  that 
while  the  whole  fundus  seems  to  move  along  with  the  motion  of 
the  lens,  the  floor  of  the  excavation  apparently  moves  in  the 
same  direction,  but  at  a  slower  rate.  This  parallax  is  the  more 
marked  the  deeper  the  excavation.  The  phenomenon  is  ex- 
plained by  the  accompanying  figure  (Fig.  104).  If  o  be  the 
optical  centre  of  the  lens  being  used  in  the  examination,  and  h 
and  a  two  points  lying  one  behind  the  other,  the  inverted  images 
of  these  points  will  be  situated  at  h'  and  a .  The  line  a  b'  lies 
in  the  visual  line  of  the  observer ;  and,  if  the   lens  be  moved 

Fig.  104. 


upward  a  very  little,  so  that  the  optical  centre  comes  to  o\  the 
inverted  images  of  b  and  a  will  be  moved  to  b'-  and  cr.  If  the 
observer  has  not  altered  his  point  of  view,  it  will  seem  to  him 
that  the  point  b  has  made  a  more  extensive  motion  than  the 
point  a,  or  that  it  has  moved  more  rapidly  than  a,  and  has 
glided  between  a  and  the  observer.  Short  and  rapid  motions  of 
the  lens  from  side  to  side,  or  from  above  downward,  will  best 
show  the  parallax. 

In  the  upright  image  the  existence  of  an  excavation  may  be 

ascertained   by   observing  that  a  lens   of  a  different  power  is 

required  in  order  to  obtain  a  clear  image  of  the  margin  of  the 

papilla  and  of  its  floor.     The  depth  of  the  excavation  may  be 

25 


290  DISEASES   OF   THE    EYE. 

estimated  by  noting  the  difference  between  these  two  lenses ; 
e.  g.,  if  the  general  fundus  of  the  patient  be  emmetropic,  and 
the  emmetropic  observer  require  — 3  D  to  see  the  floor  of  the 
excavation,  the  depth  of  the  latter  is  about  1  mm.,  and  in  the 
same  proportion  up  to  10  D. 

Besides  being  cupped,  the  optic  papilla  becomes  atrophied 
from  the  pressure,  and  its  consequent  pallor  serves  to  aid  the 
diagnosis  between  this  and  physiological  excavation.  But  we 
meet  with  cases  in  which  the  optic  disc  is  cupped  and  pale,  and 
in  which  the  existence  of  increased  tension  is  doubtful  (vide  p. 
286).  And  here  sometimes  the  diagnosis  between  glaucoma  and 
primary  atrophy  of  the  optic  nerve,  with  cupping  of  the  disc, 
is  one  of  the  most  difficult  to  be  met  with — indeed,  it  must  some- 
times be  regarded  as  impossible.  The  examination  of  the  field 
of  vision  gives  no  help,  for  in  each  of  these  diseases  it  is  liable 
to  be  contracted.  Possibly  the  effect  of  a  myotic  on  the  intra- 
ocular pressure  may  assist  to  a  decision,  for  it  would  not  ma- 
terially influence  normal  tension,  while  it  would  reduce  abnor- 
mally high  tension.  Also  the  fact  that  in  glaucoma  the  L.M.  is 
affected  and  the  L.D.  is  almost  normal,  while  in  optic  atrophy 
the  reverse  is  apt  to  be  found. 

Around  the  margin  of  the  glaucomatous  excavation,  especially 
in  chronic  simple  glaucoma,  one  usually  sees  the  whitish  appear- 
ance termed  the  glaucomatous  ring  (Fig.  103),  which  is  said  to 
be  due  to  atrophy  of  the  choroid  from  pressure. 

A  pulsation  of  the  arteries  on  the  optic  papilla  may  be  often 
noted,  or  if  not  present  may  be  easily  produced  by  very  slight 
pressure  with  the  tip  of  a  finger  on  the  eyeball,  because  blood 
can  only  be  forced  into  these  vessels  by  a  pressure  greater  than 
that  opposed  to  it.  In  the  normal  eye  there  is  no  arterial  pul- 
sation,— and  slight  pressure  with  the  tip  of  the  finger  would  not 
bring  it  on — for  the  tension  of  the  coats  of  the  vessels  is  greater 
than  the  intraocular  tension  ;  and,  therefore,  the  blood  passes  on 
in  a  continuous  stream ;  but,  in  the  glaucomatous  eye,  the  intra- 
ocular tension  opposes  so  great  an  obstacle  to  the  arterial  flow 
that  at  the  systole  alone  can  it  make  its  w^ay  through. 


GLAUCOMA.  291 

Arterial  pulsation  also  occurs,  although  rarely,  in  exophthal- 
mic goitre  (see  Chap.  XIX)  and  it  occurs  where  the  pressure  in 
the  arteries  themselves  is  low  (weak  heart's  action,  etc.), 
although  that  in  the  vitreous  chamber  be  normal. 

The  acuteness  of  vision  is  diminished,  and  increasing  dimness 
of  sight  is  the  only  symptom  of  which  the  patient  complains. 
Besides  this,  the  field  of  vision  becomes  contracted,  in  conse- 
quence of  interruption  to  the  conduction  of  the  retinal  nerve- 
fibres  from  pressure  on  them  at  the  margin  of  the  depressed  optic 
papilla.  This  contraction  of  the  field  must  always  be  examined 
for  by  the  recognized  methods.  It  commences  at  the  nasal  side, 
as  a  rule  ;  while,  at  the  same  time,  central  vision  is  lowered,  and 
later  on  the  temporal  portion  of  the  field  becomes  contracted, 
and  gradually  absolute  blindness  is  brought  about. 

The  Light-Sense  in  glaucoma  is  defective,  both  as  regards 
L.  M.  and  L.  D.,  or  else  only  as  regards  L.  M.,  which  is  much 
greater  than  normal. 

The  progress  of  the  disease  is  extremely  slow,  extending 
often  over  several  years,  and  ends  in  total  blindness  if  un- 
treated. It  usually  attacks  both  eyes,  but  generally  one  of  them 
long  before  its  fellow.  Sometimes  chronic  simple  glaucoma, 
after  a  time,  takes  on  the  acute,  or  the  sub-acute,  form. 

Acute,  or  Inflammatory  Glaucoma.  (Also  called  Acute  Con- 
gestive Glaucoma.) — In  this  form  the  increase  of  tension  is 
always  very  marked.  In  addition  to  this,  there  are  the  follow- 
ing symptoms  : — 

Diminished  Depth  of  the  Anterior  Chamber,  from  pushing 
forward  of  the  lens  and  iris. 

Diminution  of  the  Refracting  Power  of  the  Eye,  by  reason 
of  the  nearer  approach  of  the  latter  to  a  globular  shape. 

Diminution  of  the  Amplitude  of  Accommodation  and  Anaesthe- 
sia of  the  Cornea,  owing  to  pressure  on  the  ciliary  nerves  as 
they  pass  along  the  inner  surface  of  the  sclerotic. 

Opacity  of  the  Cornea,  giving  its  surface  a  peculiar  "  steamy  " 
or  "  breathed-on  "  appearance,  due  to  oedema  of  the  corneal  tis- 
sue and  epithelium  by  infiltration  into  them  of  the  intraocular 


292  DISEASES   OF   THE    EYE. 

fluids  from  high  tension.  A  similar  opacity  of  the  cornea  is 
sometimes  seen  in  iritis  anrl  irido-choroiditis,  and  in  interstitial 
keratitis. 

Indistinctness  of  the  Pattern  of  the  Iris,  similarly  due  to 
oedema. 

Opacity  of  the  Aqueous  and  Vitreous  Humors. 

Dilatation  and  Immobility  of  the  Pupil,  the  result,  according 
to  some,  of  paralysis  of  the  ciliary  nerves,  but,  according  to 
others,  of  anaemia  of  the  iris  from  pressure  on  its  vessels.  The 
pupil  is  oval,  with  its  long  axis  vertical. 

The  Episcleral  Veins  are  large  and  tortuous,  owing  to  the 
pressure  on  the  vasse  vorticos£e  preventing  the  discharge  by 
those  channels  of  the  choroidal  venous  blood,  which  must  then 
pass  off  by  the  anterior  ciliary  veins. 

Subjective  Appearances  of  Light  and  Color,  and  colored  halos, 
or  rainbows,  around  lamps  and  candles,  are  complained  of. 
Similar  appearances  are  sometimes  experienced  by  persons  suffer- 
ing from  chronic  conjunctivitis. 

A  very  marked  symptom  of  acute  glaucoma  is  Pain,  both  in 
the  eye  and  radiating  over  the  corresponding  side  of  the  head. 
This  pain  is  often  very  violent. 

Vision  is  greatly  affected,  and  the  field  of  vision  will  be  found 
contracted  in  cases  of  some  standing. 

The  optic  papilla,  when  the  media  are  sufficiently  clear  to 
admit  of  its  being  examined,  is  seen  to  be  cupped  if  the  disease 
has  continued  sufficiently  long  to  bring  about  this  change. 

In  acute  glaucoma  we  recognize  certain  Premonitory  Symp- 
toms, viz. :  Sudden  diminution  of  the  amplitude  of  accommo- 
dation, evidenced  by  the  rapid  onset  or  increase  of  presbyopia 
and  the  consequent  necessity  for  the  higher  -j-  glasses  for 
near  work,  and  the  occasional  appearance  of  colored  halos 
around  the  flames  of  lamps  or  candles,  with  attacks  of  foggi- 
ness  of  the  general  vision.  The  duration  of  one  of  these 
foggy  attacks  may  be  from  a  few  minutes  to  several  hours. 
Such  attacks  are  apt  to  occur  after  a  sleepless  night  or  after 
a    meal,   and    are    sometimes    accompanied   with    peri-orbital 


GLAUCOMA.  293 

pains.  Slight  opacity  of  the  aqueous  humor  and  sluggishness 
of  the  pupil,  with  some  dilatation,  are  present  during  an 
attack,  but  afterward  the  eye  returns  to  its  normal  condition 
and  remains  so  for  weeks  or  months,  until  another  similar 
attack  comes  on.  Such  a  premonitory  stage  may  last  a  year 
or  longer,  but  cases  also  occur  in  which  there  is  no  premonitory 
stage. 

The  onset  of  The  True  Glaucomatous  Attack  is  usually  at 
night.  It  is  accompanied  by  violent  pain  radiating  through 
the  head  from  the  eye,  by  pericorneal  injection,  chemosis,  and 
lachrymation.  The  aqueous  humor  is  cloudy,  the  anterior 
chamber  shallow,  the  iris  discolored,  and  the  pupil  dilated 
to  medium  size  and  of  oval  shape,  the  cornea  "  steamy " 
and  anaesthetic.  The  patient  frequently  complains  of  subjec- 
tive sensations  of  light,  and  vision  is  very  defective  or  may  be 
quite  wanting.  Vomiting  very  frequently  accompanies  acute 
glaucoma,  and  has  often  led  to  errors  of  diagnosis,  the 
patient's  ailment  having  been  taken  to  be  a  gastric  disease, 
while  the  ocular  symptoms  were  regarded  as  accidental  coin- 
cidences, as  "  a  cold  in  the  eye,"  "  neuralgia,"  etc. 

An  attack  such  as  that  just  described  may,  to  a  great 
extent,  pass  away  in  the  course  of  a  few  days,  but  a  complete 
remission  of  all  the  symptoms  does  not  come  about.  Some 
defect  of  central  vision  is  left,  or,  it  may  be,  some  slight 
peripheral  defect  in  the  field  of  vision,  the  tension  does  not 
become  quite  normal  again,  and  the"  pupillary  motions  remain 
slightly  sluggish.  Another  acute  attack  of  glaucoma  comes 
on  in  the  course  of  some  weeks  or  months,  and  it,  too,  may 
pass  away,  leaving  the  eye  in  a  still  worse  condition  than  it 
found  it.  The  attacks  gradually  become  more  frequent,  and 
if,  in  the  intervals,  the  eye  be  examined,  the  cornea  and 
vitreous  humor  will  be  found  opaque,  the  optic  papilla 
cupped,  and  an  arterial  pulsation  may  be  discovered.  At 
last  there  is  no  remission  from  the  attack,  the  violent  glauco- 
matous symptoms  become  permanent,  and  all  vision  is  forever 
destroyed. 


294  DISEASES   OF   THE    EYE. 

Even  when  vision  has  been  destroyed,  the  high  tension  con- 
tinues and  gradually  produces  disorganization  of  the  tissues 
of  the  eyeball  (glaucomatous  degeneration).  The  iris  becomes 
atrophied,  the  lens  becomes  opaque,  and  the  cornea  frequently 
ulcerates,  while  hemorrhages  are  apt  to  occur  in  the  anterior 
chamber.  In  time,  the  excessive  intraocular  tension  causes 
staphylomatous  bulging  of  the  sclerotic  in  the  ciliary  region 
or  further  back,  and,  finally,  such  eyes  may  become  the  subjects 
of  acute  purulent  choroiditis,  and  end  in  phthisis  bulbi. 

Acute  glaucoma  almost  always  comes  in  both  eyes,  either 
at  the  same  time,  or  with  an  interval,  it  may  be  of  weeks,  or  of 
months. 

The  reason  why  there  is  so  marked  a  diflference  between  the 
symptoms  and  course  of  chronic  and  of  acute  glaucoma  is 
that,  in  the  former,  the  increase  of  tension  is  very  gradual, 
and,  therefore,  the  eye  becomes  accustomed  to  it,  while  in 
acute  glaucoma  the  increase  is  rapid  or  sudden,  and  the 
circulation  of  the  eye  has  not  time  to  accommodate  itself  to 
the  new  state  of  things. 

Glaucoma  Fuhninans  is  the  name  given  by  von  Graefe  to  a 
form  of  the  disease  which  is  more  acute  than  the  ordinary 
acute  glaucoma  just  described.  It  has  no  premonitory  stage, 
and,  coming  on  with  all  the  symptoms  of  acute  glaucoma 
greatly  exaggerated,  does  not  remit,  and  causes  complete 
permanent  destruction  of  vision  in  the  course  of  a  few  hours. 
It  is  a  rare  form. 

Subacute  Glaucoma. — This  form  differs  from  acute  glaucoma 
in  that  its  premonitory  stage  merges  gradually  into  the  actual 
disease,  without  the  occurrence  of  an  acute  attack.  The  eye 
gradually  becomes  hard,  the  pupil  dilated,  the  anterior  chamber 
shallow,  the  aqueous  humor  opaque,  while  the  cornea  is  "  steamy  " 
and  aniesthetic,  and  the  episcleral  veins  are  distended.  Oph- 
thalmoscopically  the  cupped  disc  and  pulsating  arteries  may  be 
seen  where  the  opacities  of  the  media  permit.  Vision  sinks, 
and  the  field  is  contracted  toward  its  nasal  side.  The  progress 
of  the  disease  is  very  slow,  and  in  its  course  attacks  of  ciliary 


GLAUCOMA.  295 

ueuralgia  with  greater  increase  of  the  tension,  greater  opacity  of 
the  aqueous  humor,  increase  of  the  corneal  opacity  and  anaes- 
thesia, and  further  dimness  of  vision,  are  experienced. 

These  attacks  pass  off  again  in  the  course  of  a  few  days  or 
hours,  leaving  the  eye  harder  and  blinder  than  before.  The 
subacute  glaucoma  sometimes  takes  on  the  acute  form.  It  is 
liable  to  bring  about  the  same  glaucomatous  degeneration  of 
the  eye  as  does  the  latter. 

Etiology  of  Glaucoma. — Glaucoma  is  a  disease  of  advanced 
life,  occurring  most  usually  after  fifty  years  of  age  and  rarely 
under  the  thirtieth  year.     It  is  not  peculiar  or  more  common  to 

Fig.  105. 


Diagrammatic  representation  of  normal  condition. 

/.  Augle  of   anterior  chamber  and  ligamentum  pectinatum.      s.    Canal  of  Schleium. 

p.  Venous  plexus  of  Leber. 

any  one  constitution  or  temperament.  Anxiety,  sorrow,  and  in- 
fluences in  general  which  depress  the  spirits,  have  often  been 
noticed  to  precede  the  onset  of  acute  glaucoma. 

As  regards  the  Pathology  of  Glaucoma,  the  theory  which  of 
late  years  has  obtained  most  acceptation  owes  its  origin  to 
Max  Knies*  and  Adolf  Weber,t  and  is  known  as  the  Retention 
Theory.  These  observers  ascertained  that,  in  glaucomatous 
eyes,  the  periphery  of  the  iris  lies  in  contact  with  the  periphery 
of  the  cornea  (Figs.  105  and  106)  in  the  region  of  the  canal  of 

*  Von  Graefe's  Archiv,  xxii,  pt.  3,  p.  163,  and  xxiii,  pt.  2,  p.  62. 
J  Ibid.,  xxiii,  pt.  1,  p.  1. 


296  DISEASES   OF   THE    EYE. 

Schlemra,  venous  plexus,  and  liganaentum  pectinatura.  But 
this  region  and  these  tissues,  having  previously  been  proved  by 
Leber*  to  be  the  ways  of  exit  of  the  effete  intraocular  fluids, 
which  flow  to  that  point  from  the  posterior  part  of  the  aqueous 
chamber  through  the  pupil,  AVeber  and  Knies  concluded  that 
the  blocking  of  these  passages  by  the  close  application  of  the 
iris  caused  glaucoma  by  preventing  the  effete  fluids  from  escap- 
ing, and  thus  the  disease  was  rendered  one  of  retention,  rather 
than  of  hypersecretion,  as  it  had  previously  been  considered  to  be. 
Weber  believes  that  swelling  of  the  ciliary  processes,  from  one 

Fig.  106. 


Diagrammatic  representation  of  glaucomatous  condition. 
/'  Obliterated  angle  of  anterior  chamber. 

cause  or  another,  pushes  the  periphery  of  the  iris  forward  and 
gives  the  starting-point  for  glaucoma. 

Brailey,t  to  a  certain  extent,  adopts  this  view  of  Weber,  but 
regards.!  ^  chronic  inflammation  of  the  ciliary  processes  and 
periphery  of  the  iris,  with  distention  of  the  blood-vessels  of  these 
parts,  to  be  the  chief  factor  in  the  earliest  history  of  the  disease. 

Priestley  Smith,§  too,  adopts  the  retention  theory,  and  holds 


*/62d,  xix,  pt.  2,  pp.  87-185.  f  Ophth.  Hosp.  Bep.,  x,  p.  285. 

X  Ibid.,  ix,  p.  199,  and  x,  pp.  14,  89,  93. 

^.  "  On  Glaucoma,"  1879,  Ophth.  Hosp.  Bep.,  x  ;  Trans.  Internal.  Med. 
Congress,  1881 ;  Ophthalmic  Review,  July,  1887.  "  Pathology  and  Treat- 
ment of  Glaucoma,"  London,  1891. 


GLAUCOMA.  297 

that  the  main  predisposing  cause  of  primary  glaucoma  is  an  in- 
sufficient space  between  the  margin  of  the  lens  and  the  structures 
which  surround  it ;  and  he  attributes  the  greater  liability  of 
elderly  people  to  the  progressive  increase  in  the  size  of  the  lens, 
which  he  has  proved*  to  occur  as  life  advances.  In  eyes  in 
which  the  circumlental  space  is  insufficient,  by  reason  either  of 
the  original  structure  of  the  eye — and  small  eyeballs,  as  Priest- 
ley Smith  has  shown,  as  specially  liable  to  primary  glaucoma,  a 
fact  often  demonstrated  by  the  small  size  of  the  cornea  in  the 
eyes  attacked — or  of  the  enlargement  of  the  lens,  any  condition 
which  tends  to  overfill  the  veins  of  the  head  and  uveal  tract  may 
initiate  an  attack  of  acute  glaucoma,  as  follows :  An  increase  in 
the  amount  of  blood  in  the  uveal  tract  must  be  compensated  by 
the  expulsion  of  some  other  fluid  from  the  eye — the  aqueous 
humor  filters  out  more  rapidly  at  the  angle  of  the  anterior 
chamber.  As  the  contents  of  the  chamber  diminish,  the  lens 
and  iris  move  forward  toward  the  cornea.  Now,  in  the  normal 
eye,  and  especially  in  the  youthful  eye,  this  compensation  is 
eflfected  without  danger  to  the  angle  of  the  anterior  chamber, 
because  the  lens  is  comparatively  small,  the  circumlental  space 
large,  and  the  anterior  chamber  deep.  But  when  the  lens  and 
ciliary  processes  are  already  in  close  relation  to  each  other,  and 
the  anterior  chamber  already  shallow,  then  any  increased  full- 
ness of  the  uveal  tract  involves  danger  to  the  angle  of  the 
chamber.  The  turgid  ciliary  processes  find  insufficient  space 
for  their  expansion ;  they  are  carried  forward  together  with  the 
lens,  and,  pressing  upon  the  base  of  the  iris,  lock  up  the  angle 
of  the  anterior  chamber.  Thereupon,  the  further  escape  of 
fluid  being  impossible,  high  tension  of  the  eyeball  is  estab- 
lished. According  to  this  explanation,  then,  the  high  tension 
is  due  to  impeded  escape  of  the  intraocular  fluid,  not  to  hyper- 
secretion, and  depends  primarily  rather  upon  an  increase  in  the 
amount  of  blood  in  the  eye  than  on  an  excess  of  the  intraocular 
fluid.      Mr.  Priestley  Smith   considers  that  in  chronic  simple 

*  Trans.  Ophth.  Soc.  United  Kingdom,  iii,  p.  79. 


298  DISEASES   OF   THE   EYE. 

glaucoma  the  predisposing  causes  are  the  same  as  in  acute  glau- 
coma, but  that  in  the  former,  the  vascular  disturbance  being 
gradual  and  slight,  the  vessels  adapt  themselves  to  the  slowly 
increasing  pressure,  and  the  angle  of  the  anterior  chamber  is 
more  or  less  compressed,  but  not  tightly  closed. 

Von  Graefe*  believed  that  a  serous  choroiditis  lay  at  the  root 
of  the  disease,  which  he  thought  was  caused  by  exudation  of 
serous  fluid  into  the  vitreous  humor ;  while  Donders,t  von  Hip- 
pel  and  Grunhagen,J:  and  others,  held  that  irritation  of  the  fifth 
pair  of  nerves,  governing  the  secretion  of  the  intraocular  fluids, 
gave  rise  to  hypersecretion  of  those  fluids. 

Others,  again,  held  that  changes  in  the  sclerotic,  rendering  it 
rigid,  and  leading  to  some  shrinking  of  it,  caused  the  increased 
intraocular  tension. 

Laqueur§  believes  that  some  such  sclerotic  changes  produce 
obstruction  of  the  posterior  ways  of  exit  of  the  intraocular 
lymphatics,  namely,  those  which  pass  out  with  the  four  vasse 
vorticosse,  and  that  glaucoma  depends  largely  upon  this  obstruc- 
tion. 

Treatment. — The  performance  of  an  iridectomy  is  the  means 
discovered  by  von  Graefe,||  in  the  year  1857,  for  the  cure 
of  glaucoma,  a  disease  which  had  hitherto  been  incurable. 
This  measure  held  an  undisputed  position  as  the  sovereign 
remedy  for  the  disease  until  a  few  years  ago,  and  even  yet 
has  not  suffered  much  from  the  competition  of  the  operation 
of  sclerotomy. 

To  insure  the  success  of  an  iridectomy  for  glaucoma,  so 
far  as  possible,  it  is  necessary :  1.  That  the  incision  should 
be  peripheral,  ^.  e.,  as  far  back  in  the  corneo-sclerotic  margin 
as  is  compatible  with  the  introduction  of  the  knife  into  the 
anterior   chamber,  and    with   the  avoidance   of  injury  to   the 

*  Archivf.  OphthaL,  xv,  pt.  3,  p.  108,  and  elsewhere. 

f  Ibid.,  ix,  pt.  2,  p.  215.     Xlbid.,  xiv,  pt.  3,  xv,  pt.  1,  and  xvi,  pt.  1. 

'i  Von  Graefe' s  Archiv,  xxvi,  pt.  2. 

jl  Archivf.  Ophthal,  iii,  pt.  2,  p.  456. 


GLAUCOMA.  299 

ciliary  body.  2.  That  the  portion  of  iris  removed  should 
be  wide,  i.e.,  involving  about  one-fifth  of  the  entire  circum- 
ference of  the  iris  (see  p.  246  and  Fig.  98). 

It  is,  moreover,  important  to  withdraw  the  knife  very 
slowly  from  the  anterior  chamber  when  the  corneo-sclerotic 
section  is  complete,  in  order  that  the  aqueous  humor  may 
flow  off  gradually,  and  the  occurrence  of  an  intraocular 
hemorrhage  from  the  sudden  reduction  of  tension  be  avoided. 
The  portion  of  iris  should  be  most  carefully  abscised, 
so  that  DO  tag  of  it  may  remain  in  the  wound  and  become 
caught  in  the  cicatrix  in  the  course  of  healing.  Such  an 
occurrence  is  apt  to  produce  a  cystoid  cicatrix,  which  may 
at  a  later  period  become  the  starting-point  of  irritation, 
and  even  of  serious  inflammation.  Some  operators  prefer 
von  Graefe's  cataract  knife  for  the  performance  of  the  opera- 
tion, but  the  ordinary  lance-shaped  iridectomy  knife  is  the 
instrument  usually  employed.  For  the  purpose  of  reducing 
the  intraocular  tension,  it  matters  nothing  what  region 
of  the  iris  be  abscised ;  but,  as  a  rule,  the  upper  quadrant 
is  to  be  preferred,  for  there  the  resulting  coloboma,  being 
covered  to  a  great  extent  by  the  upper  lid,  will  give  rise  to 
less  diffusion  of  light  than  in  any  other  position. 

Immediately  after  the  operation,  palpation  of  the  eyeball 
should  show  a  marked  diminution  of  tension.  When  this  is 
not  so,  the  prognosis  is  unfavorable.  Should  an  increase  of 
tension  occur  on  the  day  after  the  operation  it  is  of  no  con- 
sequence, as  it  passes  off  again  in  the  course  of  the  next  few 
succeeding  days.  Until  then  the  anterior  chamber  will  not 
be  restored,  and  we  see  cases  where  the  anterior  chamber  does 
not  appear  for  a  week  or  more.  The  bandage  should  be  worn 
until  the  anterior  chamber  is  completely  restored.  I  do  not 
care  for  the  use  of  eserine  after  a  glaucoma  operation,  as  I 
think  it  sometimes  produces  iritis.  Von  Graefe  recommended 
that  if,  immediately  after  the  iridectomy,  the  intraocular 
tension  continue  high,  no  bandage  should  be  applied,  as  he 
believed   it   to   do   harm,  but   advised  that  the   eyelids  should 


300  DISEASES    OF    THE    EYE. 

simply  be  kept  closed  with  a  strip  of  court  plaster.  The  pain 
for  some  time  after  the  operation  is  considerable,  but  may 
be  relieved  by  a  hypodermic  injection  of  morphia  in  the 
corresponding  temple. 

Very  occasionally,  immediately  after  iridectomy,  although 
the  operation  may  have  been  faultlessly  performed,  the  case 
takes  what  we  call  a  "malignant"  course.  In  these  cases 
the  lens  seems  to  be  violently  pushed  forward,  blocking  the 
wound,  obliterating  the  angle  of  the  anterior  chamber,  and 
preventing  any  fluid  from  escaping  from  the  eye,  so  that  very 
soon  it  is  hard,  or  harder,  than  before.  This  complication 
seems  to  be  caused  by  the  retention  of  fluid  behind  the  lens, 
and  is  more  likely  to  occur  in  cases  of  chronic  simple  glau- 
coma than  in  the  acute  forms  of  the  disease. 

Unless  the  method  recommended  by  Adolf  Weber  for  these 
cases  be  employed  wdth  success,  all  such  eyes  are  inevitably 
lost,  are  apt  to  become  very  painful,  and  must  often  be  excised. 
Weber*  introduces  a  broad  needle,  or  a  Graefe's  knife,  through 
the  sclerotic,  8  or  10  mm.  behind  the  outer  margin  of  the  cornea, 
and  gives  the  blade  a  quarter  turn  on  its  axis,  so  as  to  make 
the  wound  to  gape.  At  the  same  time  he  applies  a  gradually 
increasing  pressure,  by  means  of  the  upper  lid,  on  the  centre  of 
the  cornea.  This  causes  fluid  to  escape  through  the  scleral 
wound  by  the  side  of  the  knife,  and  it  also  causes  the  lens 
to  go  back  into  its  place,  with  restoration  of  the  anterior 
chamber.  The  pressure  on  the  cornea  may  be  maintained, 
with  advantage,  for  a  minute  or  somewhat  longer.  Mr. 
Priestley  Smith  speaks  highly  of  this  procedure,  but  I  am 
happy  to  say  I  have  not  had  the  necessity  to  resort  to  it. 

As  a  rule,  the  more  acute  the  form  of  glaucoma,  and  the 
earlier  in  the  disease  the  iridectomy  is  performed,  the  more 
favorable  is  the  prognosis  in  respect  of  the  result  which  may 
be  expected.  The  saving  of  normal  vision  can  only  be  looked 
for  in  those  cases,  chiefly  of  acute  form,  where  it  has  as  yet 

*Von  Graefe's  Archiv,  xxii,  1,  p.  86. 


GLAUCOMA.  301 

fallen  but  little,  or  not  at  all,  below  the  normal,  and  where 
the  contraction  of  the  field  has  barely  commenced.  When 
the  disease  has  interfered  seriously  with  vision  (of  course  I 
do  not  refer  here  to  the  enormous  loss  of  sight  immediately 
attendant  upon  an  attack  of  acute  glaucoma,  for  this  is  usually 
restored),  we  should  not  expect  more  than  the  retention  of  the 
status  in  quo.  But  our  prognosis,  even  in  this  respect,  should 
be  most  guarded,  especially  in  chronic  simple  glaucoma, 
when  the  contraction  of  the  field  is  found  to  have  approached 
close  to  the  fixation  point,  although  central  vision  may  be 
fairly  good.  Because,  in  such  cases,  while  the  iridectomy 
may  prove  successful  so  far  as  reduction  of  tension  is  con- 
cerned, yet  the  contraction  of  the  field,  i.  e.,  the  progress  of 
the  atrophy  of  the  optic  nerve,  is  often  not  arrested,  and 
shortly  afterward  may  be  found  to  engulf  the  centre  of 
vision.  I  go  so  far  as  to  think  that  in  such  cases  any  opera- 
tion is  liable  rather  to  hasten  than  to  retard  the  blindness, 
and  I  therefore  never  operate  on  them.  It  may,  indeed, 
be  stated,  that  while  the  result  obtained  from  iridectomy 
in  acute  and  subacute  glaucoma,  on  the  bases  above  laid 
down,  can  be  regarded  as  amongst  the  most  satisfactory  in 
the  whole  range  of  ophthalmology,  in  chronic  simple  glau- 
coma iridectomy  does  not  act  with  the  same  degree  of  success, 
and  the  prognosis  should  therefore  be  guarded  in  these  cases. 

In  cases  of  acute  or  subacute  glaucoma,  it  has  frequently 
been  observed  that  shortly,  even  within  a  few  hours,  after 
the  performance  of  the  iridectomy  the  other  eye,  previously 
healthy,  or,  at  most,  affected  with  but  slight  premonitory 
symptoms,  is  attacked  with  glaucoma.  It  is  probable  that 
this  is  due  to  dilatation  of  the  pupil,  with  crowding  of  the 
iris  into  the  angle  of  the  anterior  chamber,  in  consequence 
of  confinement  in  the  dark  room. 

It  may  here  again  (vide  p.  238)  be  stated  that  the  use 
of  atropine,  or  of  any  other  mydriatic,  in  an  eye  with  a 
tendency  to  glaucoma,  is  liable  to  bring  on  an  acute  attack 
of  the  disease,  and  must  be  carefully  avoided  in  such  cases. 

If  the  tension  be  not  relieved  by  the  iridectomy,  a  supple- 


302  DISEASES    OF   THE    EYE. 

mental  iridectomy  may  be  performed  after  a  time,  and  von 
Graefe  recommended  that  it  should  be  placed  at  the  opposite 
side  of  the  pupil  from  the  first  coloboma. 

The  Mode  of  Action  of  the  Operation  is  not  clearly  known. 
Von  Graefe  at  one  time  believed  it  to  act  by  diminution  of 
the  secreting  surface  of  the  intraocular  fluids.  De  Wecker* 
and  Stellwagt — even  previously  to  the  formulation  by  Knies 
and  Weber  of  the  retention  theory  of  glaucoma  already  referred 
to — held  that  the  cure  depended,  not  on  the  removal  of  the 
portion  of  iris,  but  on  the  incision  in  the  corneo-sclerotic 
margin,  or  rather  on  the  nature  of  the  cicatrix  resulting 
from  that  incision.  They  maintained  that  this  cicatrix  was 
formed  of  tissue  which  admitted  of  a  certain  amount  of  fil- 
tration through  it  of  the  intraocular  fluids,  and  that  in  this 
way  the  intraocular  tension  was  kept  down  to  the  normal 
standard.  This  theory  has  gained  support  from  that  of  Knies 
and  Weber. 

Priestley  Smith  has  satisfied  himself  that  in  a  large  number  of 
successful  iridectomies  the  success  is  due  to  a  permanent  corneo- 
scleral fistula — not  merely  a  filtration  cicatrix — having  been 
formed.  The  same  view  is  held  by  Treacher  Collins,t  who 
finds  that  this  permanent  gap  is  maintained  by  a  prolapse  of  a 
fold  of  iris  into  the  wound.  The  latter  author,  indeed,  entirely 
and  definitely  discards  the  filtration-cicatrix  theory,  for  which  he 
considers  there  is  no  evidence.  In  those  cases  where  a  fistula,  as 
described,  is  not  formed  by  the  operation,  Treacher  Collins  con- 
siders that  the  obstruction  becomes  freed,  either  by  the  iris 
being  torn  away  at  its  thinnest  part,  that  is,  its  extreme  root, 
thus  leaving  a  large  portion  of  the  filtration  angle  open  for 
drainage,  or  by  the  escape  of  the  aqueous  and  drag  on  the  iris, 
incident  on  the  iridectomy  being  sufficient  to  dislodge  the 
periphery  of  an  iris  which  has  only  recently  come  into  apposi- 
tion with  the  cornea. 


*Bericht  der  Ophihal.  Gesellsch.  zu  Heidelberg,  1869. 
J  Der  Intraoculare  Bruck,  etc.    Vienna,  1868. 
t  Roy.  Loud.  Ophthal  Hosp.  Rep.,  Dec,  1891. 


GLAUCOMA.  303 

De  Wecker,  Stellwag,  *  and  Quaglinof  sought  to  produce  the 
corneo-scleral  filtration-cicatrix  without  the  removal  of  a  portion 
of  iris.  The  peripheral  position  of  the  wound,  however,  ren- 
dered the  proceeding  difficult  or  impossible,  owing  to  the  ten- 
dency to  prolapse  of  the  iris  which  necessarily  existed.  The 
introduction  of  eserine  into  ophthalmic  practice  at  last  enabled 
de  Wecker  to  place  the  operation  on  a  surer  footing,  as  the 
myosis  produced  by  instillation  of  a  solution  of  this  drug  into 
the  eye  insured  the  operator,  to  a  great  extent,  against  the 
danger  of  prolapse  of  the  iris,  and  hence 

Sclerotomy,  as  the  operation  is  called,  has  come  to  be  cultivated 
as  a  method  for  the  relief  of  glaucoma,  and  has  proved  useful  as 
such.  It  has  hitherto  been  employed  more  in  chronic  simple 
glaucoma,  a  form  in  which,  as  I  have  stated,  iridectomy  is  less 
satisfactory  than  in  acute  or  subacute  glaucoma.  Care  must  be 
taken  that  the  pupil  is  contracted  to  pinhole  size  or  nearly  so, 
when  the  operation  is  about  to  be  performed,  as  otherwise  the 
danger  of  prolapse  of  the  iris  is  very  great.  In  those  cases  where 
eserine  will  not  produce  a  sufficient  myosis,  sclerotomy  should 
certainly  not  be  performed. 

Priestley  Smith  and  Treacher  Collins  explain  the  cure  by 
sclerotomy  in  the  same  way  as  they  do  that  by  iridectomy. 

The  instrument  usad   for   performing   the   operation    is   von 
Graefe's  cataract  knife.     A  speculum  having  been  applied  and 
the  eyeball  fixed,  the  point  of  the  knife 
is   entered    into   the    anterior    chamber  ^^*c    '* 

through  the  corneo-sclerotic  margin  at  a 
point  of  its  circumference  corresponding 
to  that  selected  for  the  puncture  in  cata- 
ract extraction,  but  1  mm.  removed  from 
the  corneal  margin,  as  represented  at  a  in 
Fig.  107.     The  counter-puncture  is  made  at  a  point  (h)  corre- 

*  Bericht  der    Ophthal.    Gesellsch.   zu   Heidelberg,    1871;     Chirurgie 
Oculaire,  p.  212.     Paris,  1879. 
t  Annali  di  Ophthalmologia,  i,  pt.  2,  p.  200,  1871. 


304  DISEASES   OF   THE    EYE. 

spending  to  this,  at  the  other  side  of  the  anterior  chamber. 
With  a  sawing  motion  of  the  knife  the  section  is  enlarged 
upward,  until  only  a  bridge  of  tissue,  about  3  mm.  broad, 
remains  at  c,  and  this  is  left  undivided,  the  better  to  guard 
against  prolapse  of  the  iris.  The  knife  is  now  slowly  withdrawn 
from  the  eye,  care  having  been  first  taken  that  the  aqueous 
humor  is  thoroughly  evacuated,  which  can  be  effected  by  tilting 
the  edge  of  the  knife  slightly  forward,  so  as  to  make  the  lips  of 
the  wound  gape  somewhat.  If  the  pupil  be  quite  round  at  the 
conclusion  of  the  operation,  the  bandage  may  be  applied,  a  drop 
of  solution  of  eserine  having  been  first  instilled.  But  if  the 
pupil  be  oval  or  of  other  irregular  shape,  a  tendency  to  prolapse 
of  the  iris  is  indicated,  and  the  hard  rubber  or  silver  spatula 
should  be  introduced  into  the  anterior  chamber,  to  restore  the 
pupil  to  its  normal  shape  by  gentle  pushing  of  the  iris.  If  there 
be  an  actual  prolapse  of  the  iris,  an  attempt  may  be  made  to 
repose  it  with  the  spatula,  but  should  this  not  prove  satisfactory, 
the  prolapse  is  to  be  abscised  with  scissors,  thus  turning  the 
sclerotomy  into  an  iridectomy. 

The  Treatment  of  Glaucoma  by  Myotics. — Eserine  and  pilocar- 
pine as  eye-drops  in  two  per  cent,  solutions  often  have  the  power 
of  reducing  glaucomatous  tension.  This  power  depends  on  the 
contraction  of  the  pupil  and  consequent  drawing  away  of  the  base 
of  the  iris  from  the  angle  of  the  anterior  chamber,  and  if  the 
myotic  does  not  contract  the  pupil  greatly  it  will  not  reduce  the 
tension.  Cases  of  acute  glaucoma,  brought  on  by  the  injudicious 
use  of  atropine,  may  frequently  be  completely  and  permanently 
relieved  by  a  myotic  instilled  a  few  times.  In  acute  glaucoma 
of  the  ordinary  type,  the  use  of  a  myotic  in  the  premonitory 
stage  will  often  postpone  the  true  glaucomatous  attack,  and  even 
sometimes  relieve  the  latter  for  the  time,  but  the  myotic  treat- 
ment cannot  produce  a  radical  cure,  and  it  should  only  be  used 
to  preserve  the  health  of  the  eye  until  the  operation  is  per- 
formed. In  chronic  simple  glaucoma,  also,  myotics  bring  down 
the  tension  if  they  contract  the  pupil,  and  may  be  used  in  those 
cases  where  the  patient   will   not  submit  to  an   operation,    or 


GLAUCOMA.  305 

where  an  operation  in  the  fellow  eye  has  not  resulted  satisfac- 
torily, or  where  an  operation  is  contraindicated  by  a  very  con- 
tracted field.  The  anti  glaucomatous  action  of  the  myotic  only 
lasts  so  long  as  the  pupil  is  contracted,  and  if  the  pupil  cannot 
be  contracted  no  such  action  is  to  be  looked  for. 

In  the  myotic  treatment  of  glaucoma,  Priestley  Smith  recom- 
mends the  combination  of  cocaine  with  the  myotic,  in  such  pro- 
portions (say,  about  4-  per  cent,  of  cocaine  to  one  per  cent,  of  the 
myotic)  that  the  myotic  will  have  the  mastery  over  the  pupil. 
For  although,  like  every  dilator  of  the  pupil  when  used  alone, 
cocaine  may  promote  high  tension,  yet  as  it  has  the  powers, 
invaluable  in  glaucoma,  of  contracting  the  ciliary  blood-vessels 
and  of  diminishing  the  sensibility  of  the  ciliary  nerves,  and  when 
used  in  the  foregoing  manner  the  advantage  of  each  drug  may 
be  obtained  without  any  of  the  disadvantages  of  either. 

It  may  be  here  once  more  stated  that  while  myotics  possess 
the  power  of  reducing  glaucomatous  tension,  atropine  and  all 
mydriatics  used  alone  bring  on  glaucoma  where  there  is  already 
a  tendency  to  it.  In  all  old  people,  therefore,  before  atropine  is 
used,  it  is  well  to  ascertain  that  the  tension  is  not  too  high. 

Treatment  of  Painful  Blind  Glaucomatous  Eyes. — Eyes  blind 
of  acute  glaucoma  may,  as  I  have  stated,  continue  to  be  painful, 
and  may  in  this  way  render  the  patient's  life  very  miserable. 
Iridectomy  is  very  commonly  performed  to  relieve  the  pain, 
although  all  hope  of  restoration  of  sight  is  lost,  but  the  operation 
sometimes  fails  in  its  object.  Neurectomy  (Chap.  X,  p.  270) 
seems  to  offer  a  more  certain  result,  and,  of  course,  enucleation  or 
evisceration  would  have  the  same  efiect. 

Secondary  Glaucoma. 
In  addition  to  the  different  forms  of  primary  glaucoma  above 
described,  we  find,  as  already  stated,  that  high  tension  occurs  as 
a  sequel  of  diseased  conditions  previously  existing  in  the  eye. 
There  are  several  different  diseased  states  which  are  liable  to 
become  complicated  with  glaucomatous  tension,  but  it  should  be 
clearly  understood  that  in  almost  every  instance  the  immediate 
26 


306  DISEASES   OF   THE   EYE. 

cause  of  the  high  tension  is  the  same  as  in  primary  glaucoma, 
namely,  a  closure  of  the  angle  of  the  anterior  chamber.  The 
following  are  the  chief  conditions  which  are  liable  to  lead  to  sec- 
ondary glaucoma : — 

a.  Complete  Posterior,  or  Ring  Synechia  {vide  p.  236).  The 
iris,  being  pushed  forward  by  the  aqueous  humor  pent  up  behind 
it  in  the  posterior  part  of  the  aqueous  chamber,  is  pressed  tightly 
against  the  cornea  and  obliterates  the  angle  of  the  anterior 
chamber  and  the  ways  of  exit.  An  iridectomy  relieves  the  high 
tension  here. 

b.  Perforating  Wounds  or  Ulcers  of  the  Cornea,  followed  by 
incarceration  of  the  iris  in  the  resulting  cicatrix.  The  iris 
being  drawn  tautly  toward  the  cornea,  a  large  portion,  or  the 
whole,  of  the  filtration  angle  may  be  closed  by  it.  An  iridec- 
tomy is  indicated.  Lang  divides  anterior  synechise  by  means  of 
his  twin  knives. 

c.  Dislocation  of  the  Crystalline  Lens  into  the  Anterior 
Chamber.  Here  the  normal  flow  of  the  intraocular  fluids 
through  the  pupil  (vide  p.  296),  on  its  way  to  the  filtration 
angle,  is  arrested  by  reason  of  the  presence  of  the  lens  in  the 
anterior  chamber.  The  onward  current  then  presses  the  iris 
against  the  posterior  surface  of  the  lens,  and  its  periphery, 
which  is  unsupported  by  the  lens,  against  the  periphery  of  the 
cornea,  and  in  this  way  the  angle  of  the  anterior  chamber  is 
closed.     Here  the  lens  must  be  removed  from  the  eye. 

d.  Lateral  (traumatic)  Displacement  of  the  Crystalline 
Lens.  The  lens,  being  pushed  in  between  the  ciliary  processes 
and  the  vitreous  humor,  drives  the  root  of  the  iris  forward 
against  the  cornea  at  that  place,  while  in  other  parts  of  the  cir- 
cumference the  displaced  vitreous  acts  in  the  same  way.  In 
these  cases,  too,  the  lens  must  be  removed. 

e.  Injury  of  the  Crystalline  Lens  (vide  Chap.  XIII).  The  swell- 
ing lens  pushes  the  iris  forward  against  the  angle  of  the  anterior 
chamber.     Evacuation  of  the  swelling  lens  should  be  performed. 

J.  After  Cataract  Extraction.  For  explanation  of  this  see 
Chap.  XIII. 


GLAUCOMA.  307 

g.  Intraocular  Tumors  (vide  p.  257).  The  growth  of  the 
tumor  gives  rise  to  a  transudation  of  serum  from  the  choroid, 
which  detaches  the  retina,  and  after  a  time  pushes  the  lens,  the 
ciliary  processes,  and  the  iris  forward,  and  thus  closes  the  filtra- 
tion angle. 

h.  Serous-Cyclitis,  or  Iritis.  Here  the  filtration  angle  is  not 
closed.  Mr.  Priestley  Smith  thinks  that  the  increased  tension  is 
due  to  diminished  filtration-power  of  the  eye,  and  perhaps  by 
tissue  changes  around  the  filtration  angle. 

Another,  and  very  peculiar,  form  of  secondary  glaucoma 
is: — 

Hemorrhagic  Glaucoma. — Retinal  hemorrhages  of  the  ordi- 
nary type  are  sometimes  followed,  a  few  weeks  later,  by 
increased  intraocular  tension,  which  generally  assumes  the 
symptoms  of  acute  or  subacute  glaucoma,  and,  more  rarely, 
those  of  chronic  simple  glaucoma.  A  satisfactory  explanation 
for  these  cases  has  not,  so  far  as  I  am  aware,  been  ofl^ered. 
When  such  a  glaucoma  has  become  pronounced,  it  is  not 
usually  possible  to  distinguish  it  from  a  primary  form  of  the 
disease. 

Treatment. — Iridectomy  in  hemorrhagic  glaucoma  is  more 
likely  to  do  harm  than  good,  the  operation  being  almost  inva- 
riably followed  by  fresh  intraocular  hemorrhages  and  by  a 
further  increase  of  tension.  Sclerotomy  is  said  by  some  to  act 
with  fairly  good  results  in  hemorrhagic  glaucoma.  The  myotic 
treatment  is  powerless. 

Congenital  Hydrophthalmos, 
also  known  as  Buphthalmos,  and  Cornea  Globosa,  is  a  disease  of 
early  childhood,  of  which  the  incipient  stages  are  believed  to 
be  intra-uteriue.  The  cornea  becomes  enormously  enlarged  in 
diameter,  the  anterior  chamber  deep,  the  iris  trembling,  and 
the  sclerotic  thinned.  Increase  of  tension,  often  attended  with 
severe  pain,  and  cupping  of  the  optic  papilla  are  usually  pres- 
ent.    The  disease  is  regarded  as  a  secondary  glaucoma,  although 


308  DISEASES    OF   THE    EYE. 

it  is  by  no  means  certain  that  it  should  not  rather  be  consid- 
ered as  a  form  of  primary  glaucoma  occurring  in  young 
children. 

Treatment. — Iridectomy  and  sclerotomy  are  alike  followed  by 
disastrous  results  in  this  disease.  The  myotic  treatment  is  the 
only  one  applicable,  and  in  a  few  cases  it  arrests  the  disease. 


CHAPTER  XIII. 

DISEASES  OP  THE  CRYSTALLINE  LENS. 

Cataract,  by  which  is  meant  an  opacity  of  the  lens,  may  be 
said  to  be  the  only  disease  of  this  part  of  the  eye.  Cataract 
may  be  complete,  i.  e.,  occupying  in  its  final  stage  the  whole, 
or  nearly  the  whole,  of  the  lens ;  or  partial,  i.  e.,  occupying  only 
part  of  the  lens,  and  with  little  or  no  tendency  to  extend  to 
other  parts  of  it. 

Complete  Cataracts. 

Of  these  the  most  common  is  Senile  Cataract.  It  occurs 
in  persons  of  over  fifty  years  of  age,  rarely  in  those  under 
forty-five  years  of  age. 

Progress,  Pathogenesis,  and  Etiology  of  Senile  Cataract.  In 
commencing  or  incipient  senile  cataract,  the  opacity  is  found 
in  the  cortical  layers  of  the  lens,  especially  at  its  equator, 
and  in  the  latter  position  can  often  only  be  detected  with 
transmitted  light  from  the  ophthalmoscope  mirror,  or  with 
oblique  light,  even  when  the  pupil  is  dilated  wdth  atropine. 
This  opacity  takes  the  form  of  lines,  or  of  triangular  sectors 
of  which  the  bases  are  toward  the  equator  of  the  lens,  while 
the  apices  are  toward  its  centre.  These  lines  and  sectors  look 
black  with  transmitted  light,  but  gray  with  oblique  light,  and 
between  them  clear  lens  substance  is  present.  Or,  incipient 
cataract  may  first  appear  as  a  diff*use  opacity  in  the  layers  sur- 
rounding the  nucleus  of  the  lens.  Or,  the  opacity  may  com- 
mence both  near  the  equator  and  around  the  nucleus  at  about 
the  same  time.  Or,  again,  the  opacity  may  in  the  beginning  be 
disseminated  through  the  cortex  in  the  form  of  flocculi,  dots, 
and  lines.      In    some   cataracts,    in    a    very    incipient    stage, 

309 


310  DISEASES   OF   THE   EYE. 

there  are  no  absolute  opacities;  but,  with  weak  transmitted 
light,  i  e.,  from  a  plane  mirror,  numbers  of  fine  dark  lines  will 
be  seen  in  the  lens,  which  vanish  and  reappear,  according  as  the 
incidence  of  the  light  is  altered,  while  a  little  later  on  true  opaci- 
ties make  their  appearance.  Gradually  the  cataract  extends  to 
other  parts  of  the  lens,  until  the  whole  cortical  portion  is  opaque. 

In  senile  cataract  the  very  nucleus  itself  does  not  become 
cataractous,  although  it  is  usually  sclerosed.  Sclerosis  of  the 
nucleus  of  the  lens  is  a  physiological  condition  of  advanced 
life,  and  will  be  found  in  many  an  eye  where  there  is  no 
cataract.  It  gives  to  the  non-cataractous  lens,  as  seen  with 
a  dilated  pupil  or  with  focal  illumination,  a  peculiar  smoky 
appearance,  which  is  often  mistaken  by  inexperienced  persons 
for  cataract;  but  examination  with  transmitted  light  will 
show  that  there  is  no  opacity.  When  a  senile  cataract  has 
become  complete,  the  sclerosed  nucleus  imparts  to  its  centre 
a  brownish  or  yellowish  hue,  while  the  other  parts  of  the 
lens  are  of  a  grayish  white.  As  a  rule,  the  most  peripheral 
layers  of  the  cortex  are  the  last  to  become  opaque.  Ac- 
cording as  the  lens  becomes  opaque,  it  swells  somewhat, 
and  the  anterior  chamber,  consequently,  becomes  a  little 
shallower. 

Until  the  whole  cortex  is  opaque,  a  clear  interval  will  be 
present  between  the  iris  and  the  cataractous  part,  and  on 
examination  with  the  oblique  light  a  shadow  of  the  iris  will 
be  thrown  on  the  cataractous  part  at  the  side  from  which 
the  light  comes,  and  the  cataract  in  this  way  is  proved  to 
be  immature.  If  the  whole  cortical  substance  be  opaque,  the 
thickness  of  the  capsule  alone  will  intervene  between  the 
pupillary  margin  and  the  opacity.  In  addition  to  this  ex- 
amination with  the  focal  light,  the  pupil  should  be  dilated, 
and  the  lens  examined  by  transmitted  light  from  the  ophthal- 
moscope mirror,  when  a  completely  opaque  cataract  should  per- 
mit of  no  red  reflection  being  obtained  in  any  direction  from 
the  fundus  oculi. 

As  soon  as  the  whole  of  the  cortical  substance  has  become 


THE    CRYSTALLINE    LENS.  311 

opaque,  the  swelling  of  the  lens  begins  to  subside,  and  the  anterior 
chamber  finally  regains  its  normal  depth.  If  there  be  no  glitter- 
ing sectors  in  the  cortex,  the  cataract  is  now  "  mature,"  or  "  ripe  ' 
for  operation,  i.  e.,  if  an  extraction  operation  be  now  undertaken, 
it  is  possible  to  deliver  the  lens  in  its  entirety ;  whereas,  prior 
to  this  stage,  some  cortical  substance  would  have  been  liable  to 
adhere  to  the  capsule,  and  be  left  behind. 

But  a  cataract  is  immature,  despite  the  absence  of  shadow  from 
the  iris,  of  the  illuminable  pupil,  and  even  though  the  anterior 
chamber  be  of  normal  depth,  if  the  cortex  present  well-marked, 
glittering  sectors.  The  glitter  of  the  different  sectors  varies  with 
the  angle  of  illumination,  so  that  the  surface  appears  faceted. 
In  such  a  lens  there  are  thin,  transparent  flakes,  as  well  as  opaque 
flakes,  close  beneath  the  capsule  ;  and,  if  extraction  be  undertaken, 
the  former  are  very  apt  to  remain  within  the  eye  in  spite  of  every 
effort  to  remove  them.  A  few  months  later  the  sectors  lose  their 
sharp  contour,  break  down,  and  finally  disappear.  We  can  then 
depend  upon  the  exit  of  the  whole  cataract. 

Yet  I  will  not  deny  that  in  persons  over  sixty  years  of  age, 
in  whom  the  nucleus  is  usually  large,  many  a  cataract  can  be 
completely  removed  which  does  not  quite  come  up  to  the  standard 
of  maturity  just  laid  down,  and  at  that  time  of  life  I  would  not 
hesitate  to  operate,  without  waiting  for  absolute  maturity,  if  the 
patient  were  materially  incommoded  for  want  of  sight. 

The  foregoing  is  the  most  common  course  of  events  in  the 
progress  of  a  senile  cataract,  but  there  is  a  rather  rare  form  of  it, 
in  which  total  opacity  of  the  cortical  layers  never  does  come 
about.  In  this  form  the  lens  is  occupied  by  radiating,  linear 
opacities  up  to  the  very  capsule,  but  between  these  opaque  lines 
there  are  clear  intervals,  which  may  even  admit  of  the  fundus 
oculi  being  examined,  although  dimly,  and  which  allow  of  a 
certain  amount  of  sight. 

After  the  stage  of  maturity  a  cataract  gradually  goes  on  to  be 
hypermature.  Here  one  of  two  changes  takes  place.  Either  the 
cortical  substance  breaks  down  and  becomes  fluid,  the  nucleus 
retaining  its  consistency  and  gravitating  to  the  lowest  part  of  the 


312  DISEASES   OF   THE   EYE. 

capsule  (Morgagnian  cataract),  or,  more  commonly,  the  cortical 
substance  dries  up,  as  it  were,  and  finally  comes  to  form,  with  the 
nucleus,  a  hard,  flat  disc.  Accompanying  these  changes  in  the 
lens  substance  are  changes  in  the  epithelium  lining  the  inner  sur- 
face of  the  anterior  capsule,  which  result  in  a  thickening  of  the 
capsule.  In  a  Morgagnian  cataract  the  fluid  cortex  finally  under- 
goes absorption,  and  the  anterior  and  posterior  capsules  come  in 
contact  (cataracta  membranacea). 

The  investigations  of  Priestley  Smith*  have  shown  that  a 
diminished  rate  of  growth  of  the  lens  precedes  the  formation  of 
cataract ;  and  it  is  held  that  the  cataractous  process  in  the  senile 
lens  is  the  result,  in  the  first  instance,  of  a  rapid  sclerosis  and 
shrinking  of  the  nucleus.  If  the  process  of  sclerosis  and  shrinking 
be  very  gradual,  cataract  does  not  appear,  because  the  cortical 
layers  of  the  lens  have  time  to  accommodate  themselves  to  the 
altered  state  of  things ;  but,  if  the  shrinkage  be  rapid,  the  cortical 
layers  cannot  so  rapidly  accommodate  themselves,  and  then  the 
fibrillse  of  these  layers  become  separated  somewhat  from  each 
other,  and  fluid  collects  in  the  interspaces.  This  fluid  it  is  which 
causes  the  disintegration  of  the  lens  substance,  gradually  leading 
to  opacity  of  the  whole  lens.  As  the  opacity  increases,  more 
fluid  is  present  in  the  lens,  and  it  is  this  which  causes  the  swelling 
of  the  lens  already  referred  to.  When  the  whole  cortex  has 
become  opaque,  the  fluid  contents  begin  to  diminish  and  the  lens 
returns  to  its  normal  size.  Senile  cataract,  then,  is  entirely  a 
local  process,  and  is  not  dependent  on  any  disordered  state  of  the 
general  health. 

The  dimensions  of  the  nucleus  vary  a  good  deal.  In  some 
cataracts  it  is  very  small,  and  these  are  called  soft  cataracts,  as 
they  consist  chiefly  of  the  soft  cortical  substance.  In  others — 
and,  as  a  rule,  in  patients  over  sixty  years  of  age — the  nucleus  is 
large,  and  these  are  called  hard  cataracts,  although  they  are  not 
hard  throughout.  The  size  of  the  nucleus  can  be  estimated 
pretty  accurately  by  the  extent  and  intensity  of  the  yellowish 

*  Trans.  Ophthal.  Soc,  1883,  p.  79. 


THE   CRYSTALLINE    LENS.  313 

or  brownish  reflection,  which  is  obtainable  by  focal  illumination 
out  of  the  centre  of  the  cataract. 

In  some  senile  cataracts  the  sclerosis  is  not  confined  to  the 
nucleus,  but  extends  to  the  cortical  layers  as  well.  This  causes 
much  disturbance  of  sight,  and  the  term  cataracta  nigra  is 
given  to  these  lenses,  from  their  very  dark  hue,  although  they 
are  not  cataracts  in  the  true  sense  of  the  term.  They  require 
operation,  and,  as  they  are  always  of  large  size,  wide  openings 
have  to  be  made  to  deliver  them. 

In  the  lenses  of  young  people  there  is  no  nucleus;  conse- 
quently, in  the  complete  cataracts  of  children  and  of  young 
adults  there  is  no  nucleus ;  the  whole  lens  becomes  opaque,  and 
the  cataract  is  always  soft.  Although  the  starting-point  of  cat- 
aract in  children  and  young  adults  cannot  be  a  shrinking  of  the 
nucleus,  as  there  is  none,  yet  the  opacity  is,  no  doubt,  due  to  the 
taking  up  of  fluid  by  the  lens. 

The  Symptoms  to  which  senile  cataract  gives  rise  consist,  in 
the  earliest  stages,  in  the  appearance  of  motes  before  the  eyes 
and  of  monocular  polyopia.  Motes  are  complained  of  also  in 
disease  of  the  vitreous  humor,  but  in  those  ca^ies  they  float  over 
a  large  portion  of  the  field  of  vision,  while  in  commencing  cata- 
ract they  occupy  always  the  same  relative  position  in  the  field. 
The  polyopia  is  the  result  of  irregular  refraction  in  the  media, 
which  causes  many  images  of  the  objects  looked  at  to  be  formed 
on  the  retina.  This  symptom  seems  to  annoy  the  patients,  more 
especially  in  the  evening,  when  they  look  at  gas  or  candle  flames, 
the  moon,  etc.  It  is  often  complained  of  before  there  is  any 
actual  opacity  in  the  lens,  at  a  time  when  only  the  clefts  filled 
with  fluid  between  the  fibrillse  can  first  be  detected  with  weak 
transmitted  light,  as  dark  lines  vanishing  and  reappearing  ac- 
cording as  the  incidence  of  the  light  is  altered. 

Gradually,  as  the  opacity  of  the  lens  extends  to  other  parts  of 
it,  the  acuteness  of  vision  becomes  aflfected,  and  this  is  the  more 
marked  the  more  the  cortex  at  the  anterior  and  posterior  poles 
of  the  lens  is  involved.  In  those  cases  where  the  equatorial  parts 
of  the  lens  are  but  little  affected,  while  the  polar  regions  are  a 
27 


314  DISEASES   OF   THE    EYE. 

good  deal  so,  the  patients  see  better  in  the  dusk,  or  with  their 
backs  to  the  light,  than  when  their  eyes  are  exposed  to  a  strong 
light.  The  reason  for  this  is  that  in  the  dusk  the  pupil  is  di- 
lated, and  light  can  pass  through  the  clearer  periphery  of  the 
lens,  while  in  a  strong  light  the  pupil  is  contracted.  On  the 
other  hand,  when  the  opacity  is  confined  rather  to  the  equator 
of  the  lens,  a  strong  light  is  not  disturbing  to  sight,  or,  if  the 
centre  of  the  lens  be  quite  clear,  a  strong  light  may  even  be 
pleasant  to  the  patient. 

But,  according  as  the  lens  becomes  more  and  more  opaque, 
the  acuteness  of  vision  is  reduced,  until,  finally,  even  large 
objects  cannot  be  discerned,  and  only  quantitative  perception  of 
light  is  left.  Some  cataracts,  when  quite  ripe,  still  admit  of 
finger-counting  at  a  few  feet. 

In  advanced  stages  of  the  disease,  as  the  opacities  occupy  a 
great  portion  of  or  the  entire  cortex,  they  are  easily  recognized 
even  by  ordinary  daylight,  often  giving  a  grayish  appearance  to 
the  pupil.  Inflammatory  exudation  in  the  area  of  the  pupil 
would  afford  a  somewhat  similar  appearance,  but  would  be 
attended  by  other  signs  of  the  previous  inflammatory  process, 
such  as  synechise,  disorganization  of  the  iris,  etc. 

The  length  of  time  occupied  by  the  ripening  of  a  cataract 
varies,  in  different  cases,  from  a  few  months  to  many  years. 
In  the  very  old  the  progress  is,  in  general,  more  rapid  than 
at  an  earlier  time  of  life.  That  form  which  commences  at  the 
equator  as  fine  lines  is  slower  than  that  with  flocculent  opacities, 
or  than  that  in  which  the  cortex  around  the  nucleus  is  likewise 
implicated  at  an  early  period. 

All  examinations  as  to  the  condition  of  the  lens  are  rendered 
easier  and  more  conclusive  if  the  pupil  be  previously  dilated  with 
atropine,  but  the  tension  of  the  eye  should  be  ascertained  before 
atropine  is  instilled,  lest  glaucoma  or  a  tendency  to  it  be  present. 

Treatment. — No  external  local  applications  nor  internal 
medicines  are  of  any  avail  in  the  treatment  of  cataract  at  any 
stage.  Kemoval  of  the  cataract  from  the  eye  by  operation  is  the 
only  cure  for  blindness  caused  by  it. 


THE   CRYSTALLINE   LENS.  315 

In  cases  of  incipient  cataract,  or  in  those,  rather,  which  have 
advanced  somewhat  beyond  this  stage,  we  often  find  that  vision 
is  improved,  or  made  more  pleasant,  by  the  wearing  of  tinted 
glasses  to  moderate  the  light.  With  commencing  cataract,  an 
emmetropic  eye  is  liable  to  become  slightly  myopic,  and  then 
low  concave  glasses  for  distant  vision  will  be  found  of  service  ; 
while  for  reading,  stenop^eic  glasses  often  give  good  results. 

Dilatation  of  the  pupil  with  atropine  is  in  many  cases  of 
the  greatest  benefit,  especially  where  the  nucleus  is  much 
more  opaque  than  the  cortical  portion,  but  sometimes  the 
diff"usion  of  light  resulting  is  most  distressing  to  the  patient, 
and  greater  impairment  and  confusion  of  vision  are  produced, 
and  for  this  reason  care  in  the  prescription  of  atropine  is 
demanded. 

Patients  with  incipient  or  advancing  cataract  may,  with 
immunity,  be  allowed  to  make  every  use  they  can  of  the 
sight  they  possess ;  and  the  surgeon  should  give  them  hints 
as  to  the  arrangement  of  light  in  their  rooms,  and  for  their 
work,  etc.,  so  as  to  enable  them  to  use  their  eyes  to  the  best 
advantage. 

The  truly  distressing  period  in  the  progress  of  cataract, 
when  both  eyes  are  aflfected,  lies  between  the  advent  of  that 
degree  of  blindness  which  incapacitates  the  patient  for  reading 
or  writing,  or  for  making  his  way  about  alone,  and  the  occur- 
rence of  maturity  or  of  that  degree  of  maturity  which  is 
deemed  requisite  for  successful  removal.  This  is  often  a 
lengthened  time ;  it  may  be  months  or  years.  Fortunately,  in 
many  instances  one  cataract  is  much  more  advanced  than  that  in 
the  other  eye,  and  then  no  such  trial  need  be  gone  through. 

Artifieial  Ripening. — In  order  to  hasten  the  maturity  of  a 
cataract,  puncture  of  its  anterior  capsule  has  been  proposed 
and  practiced  with  success,  but  has  not  been  generally  adopted, 
from  the  fear  that  it  might  set  up  iritis,  and  produce  increased 
tension  from  excessive  swelling  of  the  cataract.  Forster* 
effects   artificial    ripening  by  performing  an  iridectomy,  which 

"^Archives  of  Ophthalmology,  xi,  pt.  3,  p.  349. 


316  DISEASES   OF   THE   EYE. 

can  afterward  be  utilized  for  the  extractiou.  This  in  itself 
often  expedites  the  ripening,  probably  by  disturbing  the  arrange- 
ment of  the  lens-fibres  when  the  aqueous  humor  flows  off,  and 
Forster  promotes  the  disturbance  by  gently  rubbing  or  stroking 
the  lens  through  the  cornea,  immediately  after  the  iridectomy, 
with  the  angle  of  a  strabismus  hook.  This  same  massage  of  the 
crystalline  lens  may  be  employed  with  good  result  after  simple 
tapping  of  the  aqueous  humor  without  iridectomy.  Soon  after 
this  a  rapid  increase  in  the  opacity  is  often  noticed,  so  that  in 
from  four  to  eight  weeks  extraction  can  be  undertaken.  The 
difficulty  of  this  rubbing  or  massage  of  the  lens  lies  in  the 
estimation  of  the  pressure  to  be  applied,  for  if  it  be  excessive 
the  zonula  may  easily  be  ruptured,  with  the  result  of  loss  of 
vitreous  when  the  extraction  comes  to  be  performed.  The  best 
results  are  obtained  in  cases  of  cataract  with  a  firm  and  some- 
what opaque  nucleus,  and  where  a  certain  amount  of  opacity 
already  exists  in  the  anterior  cortical  substance.  I  occasionally 
employ  the  method,  and  with  satisfactory  results,  but  some 
operators  have  seen  iritis  follow  the  proceeding. 

The  question  whether  the  cataract  in  one  eye  should  be 
extracted  until  both  are  blind  is  often  asked  by  patients.  The 
answer  is:  A  patient  with  one  mature  cataract,  and  the  other 
progressing  toward  maturity,  should  have  the  ripe  cataract 
removed.  Hypermaturity  is  thus  avoided,  and  also  the  stage  of 
blindness  above  referred  to.  Again,  if  there  be  a  ripe  cataract 
in  one  eye,  and  not  even  incipient  cataract  in  the  other,  it  is 
often  advisable  to  operate  for  the  purpose  of  increasing  the 
binocular  field  of  vision. 

Complete  Cataract  of  Young  People. — The  spontaneous  occur- 
rence of  total  cataract  in  the  youthful  lens  is  of  rare  occurrence, 
and  its  pathogenesis  is  still  unknown. 

Treatment — Discission. 

Diabetic  Cataract. — This  is  a  complete  opacity  of  the  crystal- 
line lens  occurring  in  diabetes,  and  due  to  disturbed  nutrition. 
The  cataract  does  not  differ  in  appearance  or  consistency  from 
other  cataracts,  according  to  the  time  of  life  of  the  patient. 

Treatment  and  Prognosis. — Contrary  to  a  very  general  opinion, 


THE   CRYSTALLINE   LENS.  317 

these  cases  are  favorable  for  extraction  operatious.  I  have 
operated  on  several  cases  of  this  kind,  and  always  with  success 
save  once,  when  the  eye  was  lost  by  intraocular  hemorrhage, 
and  I  have  also  seen  such  cases  operated  on  successfully  by 
others.  There  is  no  other  method  of  restoring  sight  to  these 
patients,  who  often  live  a  long  time.  But  some  ophthalmic  sur- 
geons of  distinction  have  informed  me  that,  occasionally,  patients 
operated  on  for  diabetic  cataract  die  of  coma  within  about  a  fort- 
night or  so  after  the  operation  ;  and  they  seemed  to  think  that 
this  was  not  diabetic  coma  of  the  ordinary  kind,  but  coma  caused 
in  some  way  by  the  nervous  system  being  upset  by  the  operation. 

Complete  Congenital  Cataract— Children  are  sometimes  born 
with  crystalline  lenses  opaque  in  all  their  layers,  while  the  other 
tissues  of  the  eye  are  healthy.  With  congenital  cataract,  defects 
of  the  choroid  or  retina,  or  congenital  amblyopia  without  ophthal- 
moscopic appearances,  are  also  sometimes  present,  and  these  are 
usually  indicated  by  nystagmus. 

Treatment. — Discission. 

Partial  Cataracts. 

These  are  nearly  all  congenital. 

Central  Lental  Cataract. — This  is  a  congenital  and  usually  non- 
progressive form.  It  is  an  opacity  of  the  central  or  oldest  lens- 
fibres,  while  the  peripheral  layers  remain  clear. 

Treatment. — Discission,  or  iridectomy. 

Zonular,  or  Lamellar,  Cataract.^ — This  is  congenital,  or  forms 
in  early  infancy,  and  is  the  most  common  form  of  cataract  in 
children.  It  usually  is  present  in  both  eyes,  but  it  has  been  seen 
in  one  eye  only.  In  it  the  very  centre  of  the  lens  is  clear  (Fig.  108)  > 
while  around  this  is  a  cataractous  layer  or  zone,  and  out-  Fig. 
side  that  again  the  peripheral  layers  are  transparent. 
Most  of  these  cases  are  non-progressive,  but,  occasionally, 
the  whole  lens  does  become  opaque,  and  usually  then 
there  have  been  previously  some  slight  opacities  in  the 
otherwise  clear  cortical  layers. 

With  oblique  illumination  the  cortical  layers  of  the  lens  are 


318  DISEASES   OF   THE   EYE. 

seen  to  be  clear,  while  toward  the  centre  of  the  lens  a  uniform 
gray  circular  opacity  will  be  observed.  The  diameter  of  this 
opacity  may  be  small,  perhaps  not  more  than  3  mm.  or  4  mm.,  or 
it  may  extend  very  nearly  to  the  equator  of  the  lens.  If  the  pupil 
be  dilated,  and  the  lens  examined  with  transmitted  light,  the 
cataractous  portion  will  be  seen  as  a  more  or  less  dark  disc  in 
the  centre  of  the  lens,  while  all  around  it  is  seen  the  red  light 
reflected  from  the  fundus  oculi.  The  margin  of  the  disc  is  either 
of  the  same  degree  of  darkness  as  its  centre  or  but  little  darker, 
and  this  point  serves  to  distinguish  this  form  of  cataract  from  one 
in  which  the  whole  centre  of  the  lens  is  opaque.  In  the  latter 
case  it  is  evident  that  the  centre  of  its  opacity  must  be  darker 
than  its  margin. 

It  is  probable  that  lamellar  cataract  is  due  to  some  passing 
disturbance  of  nutrition  occurring  at  the  time  the  affected  layers 
of  the  lens  are  being  laid  down.  The  subjects  of  it  are  usually 
rickety,  as  shown  by  the  irregular  and  imperfect  development 
of  the  teeth,  and  in  rachitic  alterations  in  the  bones  of  the  skull. 
Convulsions  during  infancy,  in  these  patients,  are  common. 

The  Treatment  of  central  lental  cataract  and  of  zonular  cata- 
ract is  similar,  and  consists  in  either  discission  or  iridectomy. 
The  latter  is  very  decidedly  to  be  preferred  in  those  cases  in 
which  the  central  opacity  is  so  small  that,  on  dilatation  of  the 
pupil,  the  acuteness  of  vision,  with  the  aid  of  a  stenopseic  slit,  is 
increased  in  a  satisfactory  degree.  When  the  improvement  is 
but  slight,  the  breaking  up  of  the  lens  with  a  needle  is  indicated. 
The  advantage  of  iridectomy  over  discission,  when  the  former 
can  be  adopted,  is,  that  no  spectacles  are  afterward  required, 
and  that  the  power  of  accommodation  is  retained. 

Congenital  cataracts  may  be  needled  any  time  after  dentition 
is  completed. 

Anterior  Polar,  or  Pyramidal,  Cataract  may  be  either  con- 
genital or  acquired.  In  the  former  case  it  must  be  referred  to 
some  inflammatory  disturbance  occurring  about  the  third  period 
of  development  of  the  lens.  In  both  cases  the  mode  of  origin  of 
the  opacity  is  the  same,  whether  it  be  punctiform,  flakelike,  or 


THE    CRYSTALLINE    LENS.  319 

pyramidal ;  namely,  by  contact  of  the  lens  with  an  inflamed 
cornea.  In  foetal  life  this  may  occur  without  any  perforation  of 
the  cornea,  as  there  is  then  no  anterior  chamber.  After  birth  a 
perforating  ulcer  of  the  cornea  is  a  necessary  precursor  of  it,  but 
the  ulcer  need  not  be  central  (p.  107).  This  contact  with  an 
inflamed  and  ulcerating  cornea  may  lead  to  subcapsular  cell- 
proliferation  at  that  portion  of  the  capsule  which  is  exposed  in 
the  pupillary  area.  No  Treatment  is  required,  as  vision  is  not 
aflfected. 

Fusiform,  or  Spindle-shaped,  Cataract  is  also  congenital,  and 
is  rare.  It  consists  in  an  axial  opacity  extending  from  pole  to 
pole,  and  may  be  combined  with  central  or  lamellar  opacity. 

The  foregoing  forms  of  cataract,  with  the  exception,  perhaps, 
of  the  pyramidal  or  anterior  polar  cataract,  are  primary  ;  that  is 
to  say,  they  are  not  dependent  on,  or  the  result  of,  disease  in 
other  parts  of  the  eye. 

But  the  fact  has  to  be  recognized  that  some  diseased  states  of 
the  eye  give  rise  to 

Secondary  Cataract. 

Of  this  a  partial  kind  is 

Posterior  Polar  Cataract. — This  form  is  seen,  with  transmitted 
light,  as  a  star-shaped  or  rose-shaped  opacity  in  the  most  posterior 
layers  of  the  posterior  cortical  substance,  its  centre  corresponding 
with  the  posterior  pole  of  the  eye. 

Posterior  polar  cataract  is  usually  found  in  eyes  which  are  the 
subjects  of  disseminated  choroiditis,  retinitis  pigmentosa,  or 
diseased  vitreous  humor.  It  sometimes  progresses  and  becomes  a 
complete  cataract,  and  then  the  prognosis  for  sight  after  extrac- 
tion is  not  very  good,  owing  to  the  disease  which  is  present  in  the 
deep  parts  of  the  eye. 

The  additional  disturbance  of  sight  caused  by  the  presence  of 
posterior  polar  cataract  depends  a  good  deal  upon  its  density. 

Total  Secondary  Cataract  often  ensues  upon  contact  of  the 
lens  with  inflammatory  products  in  the  eye,  e.  g.,  where  false  mem- 
branes have  been  produced  by  inflammation  in  the  uveal  tract. 


320  DISEASES   OF   THE   EYE. 

It  is  sometimes  then  called  Cataracta  Accreta,  when  the  iris  or 
ciliary  processes  are  adherent  to  it.  Cataract  is  also  caused  by- 
detachment  of  the  retina,  intraocular  tumor,  absolute  glaucoma, 
etc.  The  reason  of  this  is,  that  the  lens,  in  these  cases,  imbibes 
abnormal  nutrient  fluid  from  the  diseased  tissues  with  which  it  is 
in  contact. 

Such  cataracts  often  undergo  a  further  degeneration,  and  be- 
come calcareous.  Calcareous  cataracts  are  easily  recognized  by 
their  densely  white,  or  yellowish  white,  appearance,  and  almost 
always  indicate  deep-seated  disease  in  the  eye,  even  when  the 
functions,  so  far  as  they  can  be  tested,  are  fairly  good. 

These  secondary  cataracts  rarely  come  within  the  range  of 
Treatment,  as  the  diseases  which  give  rise  to  them  are  usually 
destructive  of  sight.  When,  occasionally,  they  can  be  dealt 
with,  they  should  be  extracted. 

The  terra  *'  secondary  cataract"  is  also  used  in  cases  in  which, 
after  a  cataract  extraction,  the  capsule  of  the  crystalline  lens, 
which  is  left  behind,  presents  an  obstacle  to  good  sight.  This 
will  be  referred  to  again  further  on,  and  is  not  to  be  classed 
with  the  conditions  dealt  with  in  this  paragraph. 

Capsular  Cataract 
means  an   opacity  of  the  anterior  capsule,  or  of  the  capsular 
epithelium.     It  is  usually  confined   to   the   centre,  or   anterior 
pole,  and  is  most  frequently  seen  in  over-ripe  senile  cataracts 
and  in  secondary  cataracts. 

Traumatic  Cataract. 

Every  injury  which  opens  the  capsule  of  the  lens  is  liable  to 
cause  cataract,  by  reason  of  the  admission  of  some  of  the  sur- 
rounding fluids  to  the  lenticular  substance. 

Perforating  injuries  with  sharp  instruments,  or  the  entrance  of 
small  foreign  bodies — in  both  cases,  as  a  rule,  through  the 
cornea — are  the  most  common  injuries  that  produce  traumatic 
cataract.  But  blows  upon  the  eye,  without  any  perforating 
wound,  also,  although  rarely,  produce  cataract.     In  these^latter 


THE   CRYSTALLINE   LENS.  321 

cases  there  is  a  rupture  of  the  capsule,  either  at  the  equator  of 
the  lens,  or  on  its  posterior  or  anterior  surface. 

Within  a  few  hours  after  a  perforating  injury  of  the  anterior 
capsule,  the  lens  substance  in  the  immediate  neighborhood  of  the 
opening  becomes  opaque,  swells,  and  protrudes,  as  a  gray,  fluffy- 
looking  mass,  through  the  opening  and  into  the  anterior  chamber, 
where  it  breaks  up,  dissolves,  and  becomes  absorbed.  It  is  im- 
mediately followed  by  other  portions  of  the  lens  which  have  be- 
come cataractous,  until,  gradually,  the  whole  lens  may  have 
disappeared,  and  the  pupil  again  become  black.  Dr.  Marcus 
Gunn  suggests*  that  the  explanation  of  the  solution  of  the  cat- 
aract in  the  anterior  chamber  consists  in  the  fact  that  globulin 
is  normally  soluble  in  a  weak  solution  of  chloride  of  sodium, 
such  as  we  have  in  the  fluid  of  the  anterior  chamber.  The  ab- 
sorption of  a  traumatic  cataract  takes  many  weeks,  and  ulti- 
mately the  eye  sees  well,  if  a  suitable  convex  lens  be  put 
before  it. 

But  the  course  of  events  just  sketched  is  the  most  favorable 
one,  and  is  hardly  likely  to  take  place  in  a  case  which  is  wholly 
untreated.  In  the  first  place,  the  swelling  of  the  lens — especially 
if  it  be  rapid,  in  consequence  of  a  wide  opening  in  the  capsule — 
is  liable  to  irritate  the  iris  and  to  cause  iritis,  or  to  push  the 
periphery  of  the  iris  forward  against  the  periphery  of  the  cornea, 
block  the  angle  of  the  anterior  chamber,  and  cause  secondary 
glaucoma  (p.  306). 

Moreover,  violent  plastic  or  purulent  uveitis  may  come  on,  as 
the  consequence  of  the  introduction  of  infective  matter  on  the 
perforating  object,  or  foreign  body,  which  causes  the  cataract. 
Where  this  occurs,  the  case  enters  into  the  category  of  diseases 
of  the  uveal  tract,  and  the  cataract,  as  such,  becomes  a  minor 
consideration. 

Again,  we  sometimes  meet  with  traumatic  cataracts  which  do 
not  undergo  any  absorption  process,  but  simply  remain  station- 
ary,   or    in    the   course   of    years   undergo   secondary    changes 

*  Ophthalmic  Review,  1889,  p.  235. 


322  DISEASES   OF   THE   EYE. 

similar  to  those  which  occur  in  senile  cataract.  In  these  in- 
stances the  trauma  is  usually  a  blow  on  the  eye,  not  a  perforat- 
ing injury,  and  it  is  believed  that  the  rupture  of  the  capsule 
closes  soon  after  the  blow,  and,  hence,  no  lens  matter  can  escape 
into  the  anterior  chamber ;  and,  in  addition  to  this,  the  rupture 
in  many  of  these  cases  is  probably  at  the  equator  of  the  lens, 
where  the  aqueous  would  not  readily  get  access  to  the  lenticular 
substance. 

Where  the  cataract  is  produced  by  a  small,  foreign  body  flying 
through  the  cornea  and  into  the  lens,  it  is  a  matter  of  impor- 
tance, for  the  prognosis,  to  decide  whether  the  foreign  body  be 
in  the  lens  or  have  passed  through  it  into  the  deeper  parts  of 
the  eye.  In  the  former  case  we  may  hope  to  extract  it  with  the 
cataractous  lens,  while  in  the  latter  case  we  must  fear  that  it 
will  set  up  dangerous  inflammatory  reaction.  In  such  cases  the 
lens  should  be  well  searched  with  focal  illumination,  and  the 
transmitted  light  may  also  be  of  use;  but  it  must  be  remembered 
that  in  these  traumatic  cataracts  there  are  often  glittering  sectors 
in  their  deep  parts,  which  may  readily  be  mistaken  for  a  metallic 
foreign  body. 

Treatment. — The  pupil  should  be  kept  dilated  with  atropine, 
in  order  to  draw  the  iris  out  of  the  way  of  the  swelling  lens 
matter;  and  nothing  more  is  necessary  if  complications  do  not 
arise.  But  should  iritis,  or  high  tension,  come  on — and  the 
surgeon  must  constantly  test  the  tension — it  is  important,  with- 
out further  delay,  to  extract  as  much  as  possible  of  the  cataract. 
This  may  be  done  either  without  an  iridectomy,  through  a  linear 
incision  some  10  mm.  long  in  the  upper  third  of  the  cornea,  or 
with  an  iridectomy,  through  an  incision  in  the  upper  margin  of 
the  cornea. 

If  a  foreign  body  be  present  in  the  lens,  extraction  of  the  latter 
with  the  foreign  body  should  invariably  be  undertaken. 

Where  violent  purulent  or  plastic  uveitis  is  set  up  by  the 
trauma,  the  treatment  resolves  itself  into  that  for  these  inflam- 
mations. 


the  crystalline  lens.  323 

Operations  for  Cataract. 

With  regard  to  the  State  of  Health  of  the  Patient  about  to  be 
operated  on,  it  is  desirable,  as  in  every  operation,  that  it  should 
be  good.  Still,  we  have  so  often,  in  these  cases,  to  deal  with 
very  old  people,  that  we  cannot  in  every  instance  require  sound 
organs  and  a  robust  constitution ;  and,  as  a  matter  of  experi- 
ence, I  have  not  found  serious  disease  of  the  heart,  lungs,  and 
liver,  even  when  they  all  existed  in  the  same  individual,  any 
impediment  to  a  successful  operation.  Diabetes  is  no  contra- 
indication, and  even  in  the  presence  of  Bright's  disease  I  have 
operated  successfully.  Very  advanced  years  form  no  obstacle. 
I  have  frequently  operated  for  cataract  on  persons  over  eighty 
years  of  age,  and  always  with  success. 

The  State  of  the  Eye  itself  should  be  carefully  investigated 
prior  to  proposing  or  undertaking  an  operation  for  cataract,  and 
is  a  much  more  important  matter  than  the  general  health. 
Above  all  things,  it  is  to  be  determined  whether  there  be  intra- 
ocular complications  which  would  neutralize  the  result  of  a 
successful  operation,  such  as  detachment  of  the  retina,  dissemi- 
nated choroiditis,  atrophy  of  the  optic  nerve,  etc.  The  examina- 
tion of  the  eye  in  question  before  the  lens  has  become  opaque,  if 
the  surgeon  have  had  that  opportunity,  will  be  the  most  reliable 
basis  upon  which  to  go,  and,  for  this  reason  a  careful  note 
should  be  taken  of  the  condition  of  the  fundus  in  each  case  of 
incipient  cataract.  The  examination  of  the  fundus  of  the  other 
eye,  if  its  lens  be  clear,  may  help  in  determining  the  point,  in 
so  far  as  those  intraocular  diseases  are  concerned  which  are  apt 
to  be  binocular.  Again,  the  condition  of  the  anterior  capsule  of 
the  lens  should  be  observed,  for  a  defined  glistening  white  square 
patch,  about  2  mm.  broad,  situated  in  the  centre  of  the  cap- 
sule, tells  the  tale  of  intraocular  mischief.  It  cannot  be  con- 
founded with  the  more  diffused,  striated,  and  punctated  capsular 
alterations  due  to  over-ripeness. 

Finally,  the  functions  of  the  eye  should  be  examined.  With 
an  uncomplicated  cataract  of  the  most  opaque  kind  good  percep- 


324  DISEASES   OF   THE    EYE. 

tion  of  light  should  be  present,  so  that  the  light  of  a  candle  sonoe 
two  metres  distant  may  be  distinguished.  In  less  dense  cataracts 
fingers  may  he  counted  at  1  ra.  or  1.5  m.  when  full  maturity  has 
been  attained.  The  field  of  vision  must  be  examined  by  means 
of  the  "  projection  of  light,"  i.e.,  a  lighted  candle  held  in  differ- 
ent parts  of  the  field  should  be  recognized  by  the  patient,  who 
is  required  to  point  his  finger  in  the  direction  of  the  light  as  it  is 
moved  rapidly  from  one  part  of  the  field  to  another.  This  ex- 
amination can  also  be  made  by  means  of  the  light  reflected  from 
the  ophthalmoscope  mirror.  If  the  patient  fail  to  project  the 
light  in  any  direction,  a  diseased  condition  in  the  corresponding 
part  of  the  retina  may  be  suspected.  In  cases  of  very  old  un- 
complicated cataract,  the  patients  often  project  the  light  in  one 
direction,  no  matter  where  it  may  come  from.  A  certain  degree 
of  intelligence  on  the  part  of  the  patient  is  required  for  this  test. 

By  the  foregoing  means  most  intraocular  complications  of  a 
serious  nature  can  be  detected,  but  there  is  at  least  one  against 
which  I  know  of  no  safeguard,  namely,  a  small  circumscribed 
spot  of  choroido-retinal  degeneration  at  the  macula  lutea  (central 
senile  choroiditis).  After  removal  of  a  cataract  from  an  eye 
aflfected  in  this  way,  the  patient's  vision  is  so  much  improved  as 
to  enable  him  to  go  about  alone,  but  reading  will  still  remain  an 
impossibility  for  him. 

The  Cornea  should  be  Examined. — Such  corneal  opacities  as 
would  seriously  compromise  vision  may  contraindicate  the  opera- 
tion ;  but  slighter  opacities,  discernible  only  with  oblique  illu- 
mination, would  merely  diminish  the  future  acuteness  of  vision, 
and  would  require  a  corresponding  prognosis  to  be  given  before 
operation. 

The  Condition  of  the  Appendages  of  the  Eye,  too,  must  be  ex- 
amined. Should  there  be  any  conjunctivitis,  blepharitis,  or 
dacryocystitis,  it  ought  to  be  cured  or  alleviated  before  the 
operation  is  undertaken.  Very  successful  operations  may  be 
performed  in  the  presence  of  chronic  dacryocystitis,  or  granular 
ophthalmia,  but  it  is  in  all  respects  wiser  to  reduce  their 
activity  to  a  minimum. 


THE   CRYSTALLINE   LENS. 


325 


Extraction  of  Cataract. 
Linear  Extraction. — The  extraction  through  a  linear  incision 
in   the  cornea  is  applicable  only  to  soft  or  fluid  cataracts,  in 


Fig.  109. 


persons  up  to  the  age  of  twenty-five.     The  instruments  required 
are :  A  spring  lid  elevator  (Fig.  109),  a  fixation  forceps,  a  wide 


Fig.  110. 


Pi 


Fig.  111. 


Fig.  112. 


VJ 


lance-shaped  iridectomy  knife  (Fig.  110),  a  cystotome  (Fig.  Ill), 
and  a  Critchett's  spoon  (Fig.  112). 

The  speculum  having  been  applied,  a  fold  of  conjunctiva  close 
to  the  margin  of  the  cornea,  and  at  the  inner  end  of  the  hori- 


326 


DISEASES   OF   THE    EYE. 


zontal  meridian  of  the  latter,  is  seized  with  the  fixation  forceps 
(Fig.  113),  and  the  eye  fixed  by  it  throughout  the  operation 
The  point  of  the  knife  is  now  entered  into  the  cornea  in  its  hori- 
zontal meridian,  about  4  mm.  from  its  outer  margin,  and  passed 
into  the  anterior  chamber.     The  blade  of  the  knife  is  then  laid 

Fig.  113. 


in  a  plane  parallel  to  that  of  the  iris,  and  pushed  on  until  the 
corneal  incision  has  attained  a  length  of  6  or  7  mm.  The  point 
of  the  knife  being  now  laid  close  to  the  posterior  surface  of  the 
cornea — in  order  that  no  injury  may  be  done  to  the  iris  or  lens, 
when  the  aqueous  humor  commences  to  flow  off" — the  instrument 
is  very  slowly  withdrawn,  so  that  the  aqueous  humor  may  come 


Fig.  114. 


away  gradually,  without  causing  prolapse  of  the  iris.  In  with- 
drawing the  knife  it  is  well  to  enlarge  the  inner  aspect  of  one  or 
other  end  of  the  wound,  by  a  suitable  motion  of  the  instrument 
in  that  direction. 

The  knife  being  now  put  aside,  the  cystotome  is  passed  into 


THE   CRYSTALLINE   LENS.  327 

the  anterior  chamber  (Fig.  114)  as  far  as  the  opposite  pupillary 
margin,  care  being  taken,  by  keeping  the  sharp  point  of  the 
instrument  directed  either  up  or  down,  not  to  entangle  it  in  the 
wound  or  in  the  iris.  The  point  is  now  turned  directly  on  the 
anterior  capsule,  and,  by  withdrawing  the  cystotome  toward  the 
corneal  incision,  an  opening  in  the  capsule  of  the  width  of  the 
pupil  is  produced.  The  cystotome  is  then  removed  from  the 
anterior  chamber  with  the  same  precautions  as  on  its  entrance. 

The  edge  of  the  spoon  is  then  placed  on  the  outer  lip  of  the 
corneal  incision,  and  the  latter  is  made  to  gape  somewhat,  gentle 
pressure  being  at  the  same  time  applied  to  the  inner  aspect  of  the 
eye  by  the  fixation  forceps,  and  in  this  way  the  lens  is  evacuated. 
When  the  pupil  has  become  quite  black  the  operation  is  con- 
cluded. If  pressure  does  not  at  first  clear  the  pupil  completely, 
the  speculum  should  be  removed,  the  eyelids  closed,  a  compress 
applied,  and  a  few  minutes  allowed  to  elapse,  in  order  that  some 
aqueous  humor  may  be  secreted.  A  renewal  of  the  efibrts  to 
clear  the  pupil  will  probably  now  be  successful,  or,  if  not, 
another  pause  may  be  made,  and  then  fresh  attempts  employed 
until  the  pupil  is  quite  clear.  It  is  unwise  to  insert  the  spoon 
into  the  eye  to  withdraw  the  fragments,  and  if  some  of  these 
should  be  left  behind  no  ill  results  need  necessarily  follow, 
although  iritis  is  more  apt  to  supervene  than  if  the  lens  be 
thoroughly  evacuated.  Fragments  left  behind  become  absorbed. 
If  there  be  a  prolapse  of  the  iris  which  cannot  be  reposed,  it  must 
be  abscised. 

Von  Graefe,  Waldau  (Schuft),  and  Critchett  endeavored,  by 
increasing  the  size  of  the  incision,  placing  it  in  the  corneo-sclerotic 
margin,  performing  an  iridectomy,  and  introducing  a  spoon  for 
delivery  of  the  cataract,  to  make  the  linear  extraction  applicable 
to  senile  cataracts.  The  successes  derived  from  these  modifica- 
tions were  not,  however,  more  satisfactory  than  those  obtained 
from  the  old  Flap  Operation.  But  these  experiments  led 
von  Graefe  to  the  operation,  a  modification  of  which  is  now 
very  generally  employed.     He  called  his  operation 

The  Modified  Peripheral  Linear  Extraction. — The  instruments 


328  DISEASES   OF   THE   EYE. 

Fig.  115.  Fig.  116.  Fig.  117. 


Fig.  118. 


THE   CRYSTALLINE   LENS.  329 

required  are:  A  wire  lid-speculum,  a  fixation  forceps  with 
spring  catch,  a  von  Graefe's  cataract  knife  (Fig.  115),  a  curved 
iris  forceps,  an  iris  scissors,  or  a  de  Wecker's  forceps-scissors 
(Fig.  116),  a  bent  cystotome,  a  hard-rubber  spoon  (Fig.  117), 
and  a  hard-rubber,  tortoise-shell,  or  silver  spatula  (Fig.  118). 

Before  proceeding  to  operate,  the  eye  is  nowadays  thoroughly 
cocainized  by  the  instillation  of  about  three  drops  of  a  2  per 
cent,  solution  of  hydrochlorate  of  cocaine,  at  intervals  of  two  or 
three  minutes.  Previously  to  the  introduction  of  cocaine,  general 
anaesthesia  with  ether  or  chloroform  was  commonly  employed  in 
England.     I  never  used  it. 

Antiseptic  Measures,  similar  to  those  used  for  the  Three 
Millimetre  Flap  Operation  (vide  infra),  are  to  be  carefully 
attended  to. 

The  Operation. — The  speculum  having  been  applied,  the  eye  is 
steadied  by  seizing  a  fold  of  conjunctiva,  with  its  sub-coujunctival 
tissue,  close  to  the  lower  margin  of  the  cornea,  and  in  a  prolonga- 
tion of  the  vertical  meridian  of  the  latter.  The  eye  is  now 
drawn  gently  downward,  the  patient  assisting  in  the  motion. 
The  point  of  the  Graefe's  knife,  its  cutting  edge  being  directed 
upward,  is  then  entered  into  the  corneo-sclerotic  margin  at  a 
point  {A  in  Fig.  119)  about  1.5  m.  from  the  outer  and  upper 

corneal  margin,  and  2  mm.  below  the  level  of  the        ^ 

1.1  11  1  111-1  Fig.  119. 

tangent  which  would    pass  through    the  highest 

point  of  the  corneal  margin.     The  blade  is  held  in 

a  plane  parallel  to  that  of  the  iris,  and  is  pushed 

on  into  the  anterior  chamber  until  its  point  reaches 

the  point  C,  some  7  or  8  mm.  of  the  blade  being 

now^  in  the  anterior  chamber.     The  handle  of  the  knife  is  then 

lowered,  so  that  the  point  of  the  blade  is  brought  up  to  B,  where 

it  is  made  to  pass  out  through  the  corneo-sclerotic  margin,  this 

counter-puncture  corresponding  in  position,  with  reference  to  the 

corneal  margin,  to  the  point  of  entrance  A.     The  edge  of  the 

knife  is  now  turned  slightly  forward,  and  by  one  or  two  sawing 

motions  the  incision  A  B  is  completed  in  the  corneo-sclerotic 

margin.     The  blade  still  lies  under   the   conjunctiva,  which  is 


330  DISEASES   OF   THE    EYE. 

divided,  the  edge  of  the  instrument  being  turned  more  forward,  or 
even  somewhat  downward,  as  it  is  not  desirable  to  have  too  large 
a  conjunctival  flap. 

The  advantage  of  this  incision  lies  in  its  peripheral  position, 
which  is  almost  in  the  plane  of  the  crystalline  lens,  and  conse- 
quently enables  the  cataract  to  be  delivered  without  revolution 
on  its  axis.  At  a  later  period  von  Graefe  altered  the  incision,  so 
that,  puncture  and  counterpuncture  lying  as  described,  the  cen- 
tre of  the  incision  passed  through  the  apex  of  the  clear  cornea, 
instead  of  through  the  corneo-sclerotic  margin.  This,  by  making 
the  incision  more  nearly  a  segment  of  a  greater  circle  of  a  sphere, 
made  it  as  linear  as  possible,  and  consequently,  in  his  opinion,  its 
margins  adapted  themselves  more  readily. 

The  next  step  in  the  operation  is  an  iridectomy,  a  portion  of 
iris  corresponding  to  the  whole  length  of  the  wound,  or  nearly  as 
much,  being  excised.  This  iridectomy  is  necessary  or  advisable 
chiefly  because  of  the  peripheral  position  of  the  wound,  which 
would  render  prolapse  of  the  iris  very  liable  to  occur,  but  it  also 
facilitates  the  delivery  of  the  lens  and  cortical  masses.  The  sub- 
sequent stages — capsulotoray  and  delivery  of  the  lens — are  simi- 
lar in  their  details  to  those  in  the  Three  Millimetre  Flap  Opera- 
tion, to  be  presently  described. 

It  was  found  that  the  advantages  of  the  position  and  form  of 
the  incision  in  this  procedure  were  largely  counterbalanced  by 
the  danger  of  prolapse  of  the  vitreous,  the  difficulty  of  proper 
reposition  of  the  angles  of  the  coloboma,  and  the  liability  to 
cyclitis,  all  entailed  by  the  peripheral  incision,  and,  consequently, 
this  incision  has  been  abandoned  by  nearly  all  operators. 

Out  of  this  method  grew  that  one  which  is  known  as  The 
Three  Millimetre  Flap  Operation,  first  proposed  by  de  Wecker. 
I  shall  describe  the  operation  as  I  am  in  the  habit  of  performing 
it ;  and  I  may  here  say  that,  for  success  in  the  cataract  opera- 
tion, it  is  necessary  not  only  to  select  the  method  which  seems 
the  most  rational,  but  also  to  devote  the  utmost  attention  to  a 
series  of  minute  details  in  its  performance. 

Preparation  of  the  Patient. — A  gentle  purgative  is  given  the 


THE   CRYSTALLINE   LENS.  331 

day  before  the  operation,  so  that  the  bowels  need  not  be  disturbed 
for  two  days  after  the  operation.  In  the  case  of  hospital  patients, 
the  face  is  washed  with  hot  water  and  soap  shortly  before  the 
operation. 

Preparation  of  the  Eye. — Half  an  hour  before  the  operation, 
a  drop  of  a  2  per  cent,  solution  of  sulphate  of  eserine  (made 
with  a  1  in  5000  solution  of  corrosive  sublimate)  is  dropped 
into  the  eye,  and  this  is  repeated  a  quarter  of  an  hour  later. 
Just  before  the  operation,  at  intervals  of  two  minutes,  three 
drops  of  a  2  per  cent,  solution  (made  with  corrosive  sublimate 
solution)  of  muriate  of  cocaine  are  dropped  into  the  eye. 
Finally,  the  lids  having  been  everted,  the  conjunctival  sac  is 
washed  out  with  solution  of  corrosive  sublimate,  1  in  10,000, 
particular  attention  being  paid  to  the  fornix  of  each  lid  and  to 
the  inner  and  outer  canthus.  Then  the  skin  of  the  eyelids,  and 
immediate  surroundings  of  the  eye,  are  freely  washed  with  the 
same  solution. 

Preparation  of  the  Instruments. — The  instruments  required  are 
the  same  as  those  for  the  Modified  Linear  Extraction.  Imme- 
diately before  the  operation  they  are  sterilized  by  boiling ;  out 
of  the  boiling  water  they  are  plunged  for  a  moment  into  abso- 
lute alcohol,  and  laid  in  a  bath  of  a  1  in  2300  solution  of  hydro- 
naphthol  until  required  for  use. 

During  the  Progress  of  the  Operation  small  bits  of  lint,  wet 
with  the  1  in  10,000  sublimate  lotion,  are  employed  to  wipe 
away  coagula,  cortical  masses,  etc.,  and  are  not  employed  a  sec- 
ond time.  An  assistant  should  place  the  instruments  in  the 
surgeon's  hand  in  their  turn,  and  take  out  of  his  hand  those  he 
has  used,  in  such  a  manner  as  to  render  it  unnecessary  for  him 
to  look  away,  even  for  a  moment,  from  the  field  of  operation. 

The  Operation. — A  spring  wire  lid-speculum  is  applied.  The 
eye  is  fixed  with  a  catch  fixation-forceps  by  a  fold  of  conjunc- 
tiva and  subconjunctival  tissue  below  the  vertical  meridian  of 
the  cornea,  or  a  little  to  one  side  of  this  line  (Fig.  120). 

The  point  of  the  knife  is  entered  just  in  the  margin  of  the 
clear  cornea,  at  the  outer  extremity  of  a  horizontal  line  which 


332  DISEASES   OF   THE   EYE. 

would  pass  3  mm.  below  the  summit  of  the  cornea.  This  line 
is  easily  found  by  placing  the  knife,  which  is  about  2  mm. 
broad,  horizontally  across  the  cornea,  so  that  a  margin  of  clear 
corneal  tissue  1  m.  broad  «iay  remain  exposed  between  the 
knife  and  the  summit  of  the  cornea.  The  knife  is  then  passed 
cautiously  through  the  anterior  chamber,  and  the  counterpunc- 
ture  made  in  the  corneal  margin  at  the  inner  extremity  of 
the  horizontal  line  described,  and  the  incision  finished  in 
the  corneal  margin  by  a  few  slow  to-and-fro  motions  of  the  knife. 

Owing  to  the  action  of  the  eserine  the  iris  does  not  prolapse. 
The  incision,  between  puncture  and  counterpuncture,  lies  in  the 
clear  cornea  at  its  very  margin,  as  represented  by  the  dotted 
line  in  Fig.  120.  This  incision  is  no  longer  linear,  but  slightly 
curved.  It  is  found,  however,  to  adapt  itself  readily,  and,  being 
less  peripheral  than  the  true  von  Graefe  incision,  the  objections 
to  the  latter  are  obviated. 

The  Second  Stage  of  the  Operation  consists  in  an  Iridectomy. 
The  fixation  of  the  eye  having  been  given  over  to  the  assistant, 
the  iridectomy  is  performed  by  passing  a  curved  iris  forceps 
into  the  anterior  chamber,  seizing  the  smallest  possible  portion 
of  the  sphincter  of  the  iris  at  a  point  corresponding  to  the 
centre  of  the  incision,  drawing  it  out,  and  with  the  forceps- 
scissors  excising  a  very  small  central  bit  of  iris.  This  is  done, 
either  by  making  two  snips  in  the  iris,  one  at  either  side  of  and 
close  to  the  forceps,  each  of  them  reaching  to  the  periphery  of 
the  iris,  and  then  a  third  cut  which  joins  these  two  at  the  base ; 
or,  the  forceps-scissors  being  approached  from  over  the  cornea, 
the  coloboma  may  be  formed  with  one  snip  of  the  instrument, 
and,  if  care  be  taken  to  keep  the  blades  close  to  the  forceps, 
a  narrow,  neat  coloboma  may  thus  be  obtained.  It  is  unneces- 
sary to  excise'  a  large  portion  of  iris,  although  in  von  Graefe's 
original  operation  a  portion  corresponding  to  the  entire  length  of 
the  wound  used  to  be  taken  away.  A  small  coloboma,  say  of 
2  mm.  to  3  mm.  in  width,  as  in  Fig.  100,  is  sufficient  to  allow 
of  an  easy  delivery  of  the  lens  by  doing  away  with  the  resistance 
of  the  sphincter  iridis,  and  its  advantages  over  a  wide  iridectomy, 


THE    CRYSTALLINE    LENS. 


333 


Fig.  120. 


from  an  aesthetic  point  of  view,  are  obvious.  It  is  always,  there- 
fore, my  object  to  obtain  the  smallest  possible  coloboma.  The 
procuring  of  a  neat  coloboma  is  much  facilitated  if,  prior  to  the 
operation,  the  pupil 
has  been  contracted 
(see  Fig.  120)  by  the 
instillation  of  one  or 
two  drops  of  solution 
of  sulphate  of  eserine, 
as  above  recommended. 

The  Third  Stage  of 
the  operation  is  the 
Capsulotomy.  The 
operator  takes  the  fix- 
ation forceps  from  his 
assistant,  who  then 
raises  the  speculum  and  eyelids  slightly  off  the  globe,  in  order 
that  no  pressure  may  be  exerted  on  the  latter  during  the  remain- 
der of  the  operation.  The  surgeon,  passing  the  cystotome  into 
the  anterior  chamber,  divides  the  anterior  capsule  of  the  lens  by 
two  incisions,  each  from  the  lower  pupillary  margin  upward,  one 
directed  outward,  the  other  inward,  as  far  as  the  anterior  sur- 
face of  the  lens  can  be  seen,  while  finally  a  third  incision  is  made 
along  the  upper  periphery  of  the  lens.  An  extensive  opening  in 
the  capsule  is  of  great  importance,  as  otherwise  difficulty  in 
delivery  of  the  lens  may  be  experienced,  and  because  a  small 
opening  renders  the  occurrence  of  secondary  cataract  more  likely. 
In  dividing  the  capsule  it  is  important  not  to  dig  into  the  lens,  as 
this,  in  the  case  of  a  hard  cataract,  is  apt  to  dislocate  it.  A  rather 
oblique  application  of  the  cystotome  to  the  capsule  is  for  this 
reason  the  best. 

The  cystotome  often  drags  a  tag  of  the  capsule  into  the  corneal 
wound,  where  it  lies  until  the  end  of  the  operation,  and  where, 
owing  to  its  transparency,  it  may  easily  pass  unnoticed.  Such  a 
tag  acts  as  a  foreign  body,  and  may  subsequently  form  the  starting- 
point  of  troublesome  complications. 


334  DISEASES   OF   THE   EYE. 

Capsule  forceps  have  been  invented  for  the  purpose  of  taking 
away  a  large  portion  of  the  anterior  capsule,  but  this  does  not 
altogether  obviate  the  danger  of  capsule  in  the  wound,  nor  does 
it  do  away  with  the  likelihood  of  secondary  cataract.  I  have  no 
objection  to  the  method,  but  it  does  not  seem  to  have  any 
advantages  over  that  just  described  in  cases  where  the  capsule  is 
not  thickened.  When  the  capsule  is  thickened,  it  is  always 
desirable  to  tear  away  a  central  portion  of  it  with  forceps. 

Gayet,  of  Lyons,*  and  Knapp,  of  New  York,f  have  proposed 
a  method  of  opening  the  capsule  termed  peripheral  division — 
i.  e.,  they  make  only  one  opening  in  the  capsule  at  the  upper 
periphery  of  the  lens  with  a  very  sharp  "  needle  cystotome," 
which  is  passed  along  the  whole  length  of  the  corneal  section,  a 
wide  iridectomy  having  been  made  for  this  purpose.  The  chief 
advantages  claimed  for  this  method  are:  Safety  from  a  tag  of 
capsule  in  the  wound,  and  safety  from  iritis  caused  by  irritation 
from  particles  of  lenticular  substance  left  behind  after  delivery 
of  the  lens.  On  the  other  hand,  it  has  the  disadvantages 
of  the  wide  iridectomy  and  of  the  secondary  operation  on 
the  capsule,  which  is  necessary  in  a  large  proportion  of  the 
cases. 

The  Fourth  Stage  is  the  Delivery  of  the  Cataract.  The  eye 
is  drawn  gently  downward — the  patient  being  called  on  to 
assist  in  this  motion  by  looking  toward  his  feet — the  convex  edge 
of  the  hard-rubber  spoon  is  placed  just  below  the  lower  edge  of 
the  cornea,  and  gentle  pressure  is  exercised  on  this  place,  the 
pressure  to  be  gradually  increased  until  the  upper  margin  of  the 
lens  presents  itself  in  the  wound,  when,  the  same  pressure  being 
maintained,  the  spoon  is  advanced  over  the  cornea  in  an  upward 
direction,  pushing  the  lens  before  it  and  out  through  the  wound. 
As  soon  as  the  greatest  diameter  of  the  lens  has  passed  the 
wound,  the  pressure  of  the  spoon  should  at  once  be  diminished, 
lest  rupture  of  the  zonula  be  caused.     The  fixation-forceps  and 

*  Gazette  Hebdomadaire,  1875,  No.  35. 

fAi'chives  of  Ophthalmology  and  Otology,  Vol.  vi,  p.  545. 


THE   CRYSTALLINE   LENS.  335 

speculum  are  now  removed  from  the  eye,  and  a  cold  compress 
with  sublimate  lotion  is  laid  on  the  closed  lids. 

The  Fifth  Stage  consists  in  Freeing  the  Pupil  of  any  Cortical 
Masses  which  may  have  been  rubbed  off  in  the  passage  of  the 
lens  through  the  wound,  and  in  what  is  called  the  "  Toilette  "  of 
the  Wound. 

The  presence  of  cortical  remains  is  recognized  by  the  pupil  not 
having  become  quite  black ;  or,  by  the  vision  not  being  such  as 
it  ought  to  be  (fingers  counted  at  several  feet) ;  or,  by  inspec- 
tion of  the  cataract  just  removed  showing  that  some  portions  of 
it  are  left  behind.  The  use  also  .of  the  oblique  illumination  for 
the  detection  of  cortical  fragments  is  very  advantageous.  If 
any  fragments  be  present,  the  cold  antiseptic  compress  having 
lain  on  the  eye  for  a  few  minutes  to  enable  some  aqueous 
humor  to  collect,  the  operator,  facing  the  patient,  raises  the 
upper  lid  with  the  thumb  of  one  hand,  while,  with  the  first  and 
second  fingers  of  the  other  laid  on  the  lower  lid,  light  rotatory 
motions  are  made  with  this  lid  over  the  cornea  so  as  to  collect 
the  masses  toward  the  pupil,  and  then  a  few  rapid,  light  motions 
upward  with  the  margin  of  the  lid  drive  these  masses  toward, 
and  out  of,  the  wound. 

Care  and  delicacy  of  touch  are  required  in  order  to  perform 
this  lid-manoeuvre  successfully,  without  rupturing  the  hyaloid  by 
undue  pressure. 

Irrigation  of  the  anterior  chamber,  or  intracapsular  injection, 
is  a  method  which  has  been  proposed  by  M'Keown  and  by 
Wiecherkiewicz,  and  practiced  by  them  and  some  other  sur- 
geons, for  the  removal  of  cortical  masses.  By  its  aid,  too, 
M'Keown"^  operates  on  unripe  cataracts.  I  have  not  adopted 
the  procedure  in  my  own  operations,  because,  from  the  accounts 
given  of  the  results,  it  does  not  seem  to  be  free  from  danger  to 
the  eye,  and  because  the  ends  proposed  to  be  attained  by  it  can 
be  accomplished  by  other,  and  safer,  means  :  the  removal  of 
cortical  masses  in  cases  of  ripe  cataract  by  the  lid  manoeuvre ; 

*  Brit.  Med.  Jour?u,  January  28,  1888. 


336  DISEASES   OF   THE   EYE. 

while  unripe  cataracts,  so  far  as  it  is  justifiable  to  deal  with 
thera,  are  best  dealt  with  by  the  raethod  of  artificial  maturation 
proposed  by  Forster  (p.  315).  Irrigation  of  the  anterior  cham- 
ber, after  delivery  of  the  lens,  with  a  1  in  25,000  solution  of  bin- 
iodide  of  mercury,  is  used  by  Panas*  from  an  antiseptic  point 
of  view;  while  de  Wecker  and  others  inject  a  solution  of 
eserine  to  prevent  prolapse  of  the  iris.  Both  of  these  operators 
employ  the  method  of  extraction  without  iridectomy. 

With  an  iris-forceps  the  blood-clots  which  may  adhere  to  the 
wound  are  now  removed. 

I  then  invariably  employ  the  following  manoeuvre  to  prevent 
the  possibility  of  any  portion  of  capsule  being  incarcerated  in  the 
wound  during  healing.  A  bent  iris-forceps  is  passed  open 
between  the  lips  of  the  wound,  closed,  and  drawn  gently  out 
again.  Frequently  a  tag  of  capsule  will  have  been  captured  by 
the  forceps  and  is  snipped  off  with  the  scissors,  or  it  may  be  that 
no  capsule  is  caught.  The  forceps  is  then  similarly  inserted  at 
an  adjacent  part  of  the  wound,  and  in  this  manner  the  wound 
is  searched  from  end  to  end  for  capsule.  In  about  twenty-five 
per  cent,  of  the  cases  a  tag  of  capsule  is  found  present.  I  regard 
this  manoeuvre,  which  I  am  not  aware  that  any  other  surgeon 
has  previously  recommended,  as  an  important  one,  for  I  believe 
that  it  effectually  removes  the  one  serious  drawback  to  the  valu- 
able operation  under  consideration. 

Finally,  the  coloboma  has  to  be  seen  to.  The  peripheral 
portions  of  the  iris,  corresponding  to  the  ends  of  the  wound, 
are  apt  to  have  become  prolapsed  in  the  course  of  the  operation, 
and  to  have  displaced  the  angles  of  the  coloboma  upward.  If 
this  be  not  corrected,  the  prolapsed  portions  of  the  iris  heal  in  the 
wound  and  cause  bulgings  there  later  on,  the  pupil  in  the  course 
of  some  mouths  becoming  drawn  up  toward  the  cicatrix.  Hence, 
in  every  case,  even  where  everything  seems  to  be  in  order,  it  is 
important  to  pass  the  narrow  spatula  into  the  anterior  chamber, 

*  Panas's  Solution  =  Biniodide  of  Mercury  gr.  |  dissolved  in  Absolute 
Alcohol  5  vj.     Add  Distilled  Water  1  quart.     Shake  and  filter. 


THE    CRYSTALLINE    LENS.  337 

and  to  gently  stroke  down  each  pillar  of  the  coloboma  as  far  as 
it  can  be  brought.  The  instillation  of  eserine  before  the  com- 
mencement of  the  operation  will  cause  the  sphincter  iridis  to 
assist  in  producing  the  desired  result.  All  this  is  aptly  termed 
the  toilette  of  the  wound. 

The  sight  of  the  eye  should  then  be  tested  by  finger-counting, 
as  this  affords  the  patient  satisfaction,  and  lends  him  courage  for 
the  next  few  days  of  strict  quiet. 

Having  secured  the  required  advantage  from  the  effect  of  the 
eserine,  a  drop  of  atropine  is  put  into  the  eye  before  applying 
the  bandage,  in  order  to  do  away  with  the  myosis,  which  might 
give  a  tendency  to  iritis. 

The  dressing  is  now  applied.  A  piece  of  lint,  sufficiently  large 
to  extend  i  inch  beyond  the  orbital  margin  in  every  direction, 
is  soaked  in  a  solution  of  corrosive  sublimate  (1  in  5000)  and 
laid  on  the  closed  eyelids.  Pledgets  of  absorbent  cotton  wool, 
soaked  in  the  same  solution,  are  laid  on  this,  the  hollows  at  the 
inner  canthus,  etc.,  being  carefully  filled  up;  so  that,  when  the 
bandage  is  put  on,  it  may  exert  equal  pressure  on  every  part  of 
the  eye.  Over  all  comes  a  layer  of  oiled  silk  protective.  I 
apply  three  turns  of  a  narrow  flannel  roller  over  the  dressing 
and  round  the  head,  in  the  manner  which  was  customary  in  von 
Graefe's  clinique;  but  various  other,  and  doubtless  equally  good, 
forms  of  bandage  are  in  use.  The  pressure  of  the  bandage  need 
only  be  suflScient  to  maintain  the  dressing  firmly  in  its  place.  It 
is  usual  to  keep  the  other  eye  closed  by  a  light  bandage. 

I  am  opposed  to  the  after-treatment  of  cataract  operations 
without  bandage,  as  advocated  by  some  surgeons.  It  is  by  no 
means  a  new  method,  and  I  do  not  doubt  that  many  cases  re- 
cover under  it.  I  do  not  believe,  however,  that,  in  a  long  series 
of  cases,  the  same  percentage  of  recoveries  can  be  obtained  by  it 
as  with  the  bandage. 

Accidents  liable  to  occur  during  the   Operation. — The  wound 

may  be  made  too  small.     The  delivery  of  the  lens,  consequently, 

may  be  so  difficult  that  the  margins  of  the  wound  are  contused, 

and  then  suppuration  may  be  promoted.     The  zonula,  too,  may 

29 


338  DISEASES   OF   THE    EYE. 

be  ruptured  by  the  excessive  pressure  from  efforts  to  force  the  lens 
out,  and  prolapse  of  the  vitreous  may  ensue.  If  the  directions 
above  given  be  carefully  attended  to,  the  vast  majority  of  both 
hard  and  soft  cataracts  may  be  extracted  without  difficulty  ;  but 
should  the  wound  be  made  too  small,  it  can  best  be  enlarged  by 
the  forceps-scissors  or  a  blunt-pointed  knife  made  for  the  pur- 
pose. Where  the  presence  of  an  unusually  large  hard  cataract 
is  diagnosed,  it  is  important  to  make  the  incision  larger  ab  initio, 
by  placing  puncture  and  counterpuncture  nearer  to  the  horizontal 
meridian  of  the  cornea  than  above  directed. 

Hemorrhage  into  the  Anterior  Chamber  may  take  place.  It 
may  be  from  the  iris,  from  the  corneo-sclerotic  margin,  or  from 
the  conjunctiva.  Pressure  with  the  spatula  on  the  cornea,  which 
causes  the  wound  to  gape,  is  often  successful  in  clearing  the 
chamber  of  blood,  which  might  interfere  with  accurate  division 
of  the  capsule.  Still,  when  this  cannot  be  completely  got  rid  of, 
the  capsulotomy  may  be  performed  with  the  exercise  of  greater 
care.  Cocaine,  by  its  power  to  contract  the  blood  vessels,  has 
rendered  this  hemorrhage  a  less  common  complication  than  it 
used  to  be. 

Prolapse  of  the  Vitreous  Humor.  This  may  be  due  to  a  too 
peripheral  position  of  the  wound,  support  being  thus  taken  away 
from  the  zonula,  and  the  danger  of  its  occurrence  was  a  disad- 
vantage of  the  completely  corneo-sclerotic  wound  practiced  at 
one  time  by  von  Graefe.  The  Three  Millimetre  Flap  Operation 
is  less  liable  to  be  attended  with  loss  of  vitreous.  This  accident 
may  also  be  caused  by  undue  pressure  made  on  the  eyeball  by 
the  speculum,  fixation-forceps,  or  spoon,  or  by  the  under-lid  dur- 
ing the  lid-manoeuvre.  It  may  be  due  to  defective  zonula  with 
fluid  vitreous  humor.  If  the  vitreous  prolapses  prior  to  delivery 
of  the  lens,  the  latter  falls  back  into  the  eye,  and  can  only  be 
delivered  by  at  once  drawing  it  out  with  a  Critchett's,  Taylor's, 
or  other  suitable  vectis  ;  and  this  may  be  regarded  as  one  of  the 
most  serious  accidents  which  can  occur  in  the  course  of  the  opera- 
tion. Loss  of  vitreous  after  delivery  of  the  lens  is  less  serious; 
indeed,  a  considerable  portion  of  the  vitreous  may  then  be  lost 


THE    CRYSTALLINE    LENS.  339 

without  ill-result  to  the  eye.  Still,  it  increases  the  traumatism 
and  renders  inflammatory  reaction  more  liable  to  occur.  Opac- 
ities in  the  posterior  chamber  of  the  eye  are  frequently  an 
ultimate  result  of  loss  of  vitreous ;  but  a  much  more  serious  con- 
sequence is  sometimes  seen  in  detachment  of  the  retina. 

Normal  After-Progress. — Soon  after  the  completion  of  a  normal 
operation,  the  effect  of  the  cocaine  having  passed  off,  some  smart- 
ing commences  and  continues  for  four  or  five  hours.  After 
that  time  the  patient  has  no  unpleasant  sensation  in  the  eye,  unless 
it  be  some  itching,  or  a  slight  momentary  pain,  or  sensation  of  a 
foreign  body,  especially  when  the  eye  is  moved  under  the  band- 
age. The  first  dressing  is  made  in  forty-eight  hours,  in  a  man- 
ner similar  to  that  immediately  after  the  operation,  a  drop  of 
atropine  being  instilled,  as  also  at  each  successive  dressing;  and 
the  corrosive  sublimate  solution  is  used  for  freely  washing  the 
margins  of  the  eyelids,  some  of  it  being  allowed  to  trickle  into 
the  conjunctival  sac.  At  this  first  dressing  it  is  well  to  abstain 
from  a  minute  or  lengthened  examination  of  the  eye;  but,  if 
the  lid  be  gently  raised,  the  wound  will  be  found  closed,  the 
cornea  clear,  the  anterior  chamber  completely  restored,  and  the 
pupil  semi-dilated  and  black.  The  subsequent  dressings  are 
made  night  and  morning,  for  the  purpose  of  instilling  atropine. 
On  the  third  day  after  the  operation  the  patient  may  be  allowed 
to  sit  up,  the  room  being  kept  moderately  dark;  and,  on  the  fifth 
or  sixth  day  the  bandage  may  be  left  aside  permanently  and 
dark  glasses  worn  in  its  stead.  In  the  course  of  a  few  days 
more  the  patient,  having  been  gradually  used  to  more  light,  may 
be  allowed  out-of  doors.  It  is  desirable  to  continue  the  use  of 
atropine  for  about  a  fortnight  longer,  or  until  all  abnormal  vas- 
cular injection  of  the  white  of  the  eye  has  disappeared,  as,  until 
then,  there  is  danger  of  iritis.  (For  selection  of  glasses  in 
aphakia,  see  end  of  this  chapter.) 

Irregularities  in  the  Process  of  Healing. — The  pain  may  con- 
tinue longer  than  four  or  five  hours,  and  it  is  then  well  to  quiet 
it  by  a  hypodermic  injection  of  morphia  in  the  corresponding 
temple.     Should  severe  pain  come  on  some  hours  later,  it  is  apt 


340  DISEASES   OF   THE    EYE. 

to  be  due  to  an  accumulation  of  tears  under  the  eyelids,  and  it 
iranaediately  subsides  on  the  bandage  being  removed  and  exit 
given  to  the  tears  by  slightly  opening  the  eye.  Antiseptic  pre- 
cautions are  to  be  observed  while  this  is  being  done. 

Late  appearance  of  the  Anterior  Chamber.  At  the  first 
dressing  it  will  sometimes  be  found  that  there  is  no  anterior 
chamber,  although  the  appearance  of  the  wound  is  quite  satis- 
factory ;  but  this  need  occasion  no  alarm,  as  the  anterior  cham- 
ber is  sometimes  not  restored  for  a  week  or  more. 

Striped  Keratitis.  At  this  dressing  also  it  may  be  observed 
that  there  is  a  more  or  less  well-marked  striated  cloudiness  of 
the  cornea,  extending  over  nearly  the  whole  of  it,  or  occupying 
only  a  part  in  the  immediate  neighborhood  of  the  wound. 

This  opacity  is  the  result  of  injury  to  the  endothelium  of  the 
posterior  surface  of  the  cornea  during  the  operation  by  instru- 
ments, or  by  the  chemical  action  of  the  antiseptic  lotion.  Leber 
has  shown  that  the  entrance  of  even  the  aqueous  humor,  through 
a  loss  of  substance  in  the  endothelium,  is  sufficient  to  cause  the 
fibres  of  the  true  cornea  to  swell  and  become  opaque,  just  as  the 
crystalline  lens  is  acted  on  if  its  capsule  be  opened.  The  endo- 
thelium of  the  posterior  surface  of  the  cornea  in  fact  it  is,  which 
protects  the  latter  from  being  infiltrated  by  the  aqueous  humor. 

This  striped  keratitis  is,  for  the  most  part,  of  no  serious 
import,  as  it  usually  passes  away  in  a  few  days  and  leaves  the 
cornea  perfectly  clear.  But  now  and  then  cases  do  occur  in 
which  the  process  is  very  intense,  and  where  a  permanent  white 
opacity  remains  in  the  cornea  over  the  pupillary  area,  with  con- 
sequent serious  deterioration  of  vision.  These  severe  cases  are 
most  apt  to  be  caused  by  the  introduction  of  the  antiseptic  solu- 
tion into  the  anterior  chamber ;  for  the  chemical  action  of  the 
antiseptic  on  the  corneal  tissues  is  more  damaging,  and  therefore 
the  opacity  it  produces  more  permanent,  than  is  the  action  of 
the  aqueous  humor.  Sublimate  lotion  is  the  antiseptic  which 
has  been  most  often  to  blame,  probably  because  it  is  the  antiseptic 
in  most  general  use.  Even  a  sublimate  lotion  of  1  in  10,000,  if 
introduced  freely  into  the  anterior  chamber,  may  cause  the  mild 


THE   CRYSTALLINE    LENS.  341 

form  of  striped  keratitis.  Yet,  with  the  1  in  5000  solution  which 
I  have  until  recently  employed,  I  never  had  the  severe  form,  and 
rarely  the  mild  form ;  but  then  I  never  deliberately  introduced 
the  solution  into  the  anterior  chamber.  I  have  had  only  one 
case  of  the  severe  form,  and  in  it,  by  mistake,  a  sublimate  lotion 
of  1  in  2500  was  used  for  irrigation  of  the  surface  of  the  eye. 
No  doubt,  in  irrigation  of  the  surface  of  the  eye,  some  of  the 
lotion  used  is  liable  to  make  its  way  into  the  anterior  chamber. 
Boric  acid  solutions  (  3  per  cent.)  do  not  injure  the  endothelium, 
but  I  have  little  faith  in  their  antiseptic  properties. 

Suppuration  of  the  Wound.  This  is  a  danger  which  is  very 
much  rarer  than  it  was  prior  to  the  introduction  of  antiseptics 
into  surgery ;  indeed,  it  is  almost  banished  from  the  cataract 
operation.  When  it  occurs,  it  usually  does  so  between  the 
twelfth  and  thirty-sixth  hour  after  the  operation,  rarely  earlier 
or  later,  and  is  a  very  serious  event ;  for,  in  the  vast  majority  of 
cases,  do  the  surgeon  what  he  may,  it  leads  to  loss  of  the  eye. 
Its  onset  is  made  known  by  severe  pain  of  a  continuous  aching 
kind  in  and  about  the  eye,  and  is  thus  easily  distinguished  from 
the  slight,  short,  stabbing  pain,  with  long  intermissions,  which 
some  patients  complain  of  and  which  has  no  evil  import.  On 
removing  the  bandage  the  eye  will  be  found  full  of  tears  and 
the  wound  covered  with  a  layer  of  muco-pus,  which  can  be  re- 
moved with  the  forceps  in  one  mass,  while  the  aqueous  humor 
and  cornea  may  already  present  some  opacity.  In  some  hours 
more  the  corneal  opacity  increases  considerably,  the  iris  becomes 
distinctly  inflamed,  and  the  pupil  filled  with  a  mass  of  inflam- 
matory exudation.  The  inflammatory  process  may 
remain  confined  to  the  wound  and  iris,  and  when,  in 
the  course  of  some  weeks,  it  entirely  subsides,  it  leaves 
the  pupil  drawn  up  toward  the  wound,  so  that  an  ap- 
pearance as  in  Fig.  121  is  presented  ;  or  the  inflam- 
mation may  strike  into  the  ciliary  body  and  choroid,  and  produce 
purulent  panophthalmitis,  with  total  destruction  of  the  eye. 

To  combat  Suppuration,  the  best  method  is  the  immediate  cau- 
terization of  the  corneal   wound   in  its   whole  extent   with    the 


342  DISEASES   OF   THE   EYE. 

galvauo-cautery.  Also,  the  wound  may  be  opened  up  from  end 
to  end  with  a  spatula,  the  aqueous  humor  evacuated,  and  the 
anterior  chamber  washed  out  with  injections  of  corrosive  subli- 
mate solution,  while  the  conjunctival  sac  is  irrigated  with  the 
same  solution.  If  necessary,  these  measures  are  to  be  repeated 
at  intervals  of  eight  or  ten  hours. 

Iritis.  Apart  from  the  iritis  which  occurs  in  connection  with 
suppuration  of  the  wound,  this  complication  is  most  usually  due 
to  irritation  from  masses  of  cortical  lens-substance  left  behind. 
It  may  also  be  due  to  dragging  from  a  tag  of  the  iris  being  left 
in  the  wound,  or  to  too  early  exposure  to  the  daylight.  Corti- 
cal masses  do  not  usually  give  rise  to  it  for  some  days  after  the 
operation.  It  is  ushered  in  with  the  usual  symptoms  of  pain,  and 
is  generally  of  the  plastic  variety.  If  it  extend  to  the  ciliary 
body,  sympathetic  ophthalmitis  may  result.  Its  treatment  con- 
sists in  strict  confinement  to  a  dark  room,  atropine,  warm  foment- 
ations, leeching,  and,  internally,  quinine.  In  these  cases  vision 
is  liable  to  be  damaged  by  pupillary  exudation,  which  remains  as 
a  permanent  obstruction  to  vision. 

Cystoid  Cicatrix.  After  convalescence,  all  the  foregoing  dan- 
gers having  been  escaped,  the  cicatrix  in  the  corneal  margin 
sometimes  bulges  and  becomes  semi-transparent,  presenting  the 
appearance  of  a  vesicle,  and  may  attain  a  large  size.  The 
extremities  of  the  late  incision  are  the  most  common  positions  for 
this  condition,  but  it  may  occupy  the  entire  length  of  the  cica- 
trix. It  does  not  generally  come  on  for  some  weeks,  or  more, 
after  the  operation.  In  some  cases  it  is  caused  by  a  tag  of  iris 
which  is  incarcerated  in  the  wound,  but  in  other  cases  probably 
by  a  bit  of  capsule,  which  has  similarly  healed  in  the  wound. 
Irregularity  in  curvature  of  the  cornea  and  consequent  irregular 
astigmatism  are  the  least  of  its  evil  consequences.  If  the  condi- 
tion be  caused  by  incarceration  of  iris,  the  pupil  will  be  gradu- 
ally drawn  close  to  the  upper  corneo-sclerotic  margin  ;  while,  if 
it  be  caused  by  a  portion  of  capsule,  irido-cyclitis  may  be  pro- 
duced. Whether  the  iris  or  the  capsule  be  the  cause,  these  eyes 
are  always  exposed  to  the  danger  of  a  sudden  onset  of  purulent 


THE    CRYSTALLINE    LENS.  348 

irido-choroiditis  (see  p.  193).  All  this  demonstrates  the  immense 
importance  of  attention  to  those  details  of  the  operation  which 
are  calculated  to  obviate  incarceration  of  iris  or  of  capsule  in 
the  cicatrix. 

Cataract  Extraction  without  Iridectomy.* — This  method  is 
older  than  the  Linear,  von  Graefe's,  or  the  Three  Millimetre 
Flap  Operation,  and  used  to  be  known  as  The  Flap  Operation. 
It  has  been  revived  within  the  last  two  years  by  some  most  dis- 
tinguished ophthalmic  surgeons,  chiefly  in  Paris,  but  also  in  Ger- 
many and  America,  and  even  in  England.  It  differs  from  the 
Three  Millimetre  Flap  Operation  in  that  the  incision  occupies  a 
greater  extent  (about  one-third)  of  the  circumference  of  the 
cornea,  and  that  no  iridectomy  is  made.  Formerly  the  knife 
used  w^as  triangular  in  shape  (Beer's  knife),  but  von  Graefe's 
cataract  knife  is  the  instrument  now  employed.  The  round 
pupil,  and  consequent  somewhat  prettier  appearance  of  the  eye. 
is  the  one  advantage  which  can  be  claimed  for  this  procedure 
over  the  Three  Millimetre  Flap  Operation,  as  it  has  been  above 
described,  for  the  vision  with  a  circular  pupil  is  not  better  than 
where  a  small  iridectomy  has  been  done.  As  a  set-off  against 
the  circular  pupil,  the  extraction  without  iridectomy  exposes  the 
eye  to  the  serious  danger  of  prolapse  of  the  iris  into  the  wound. 
These  operators  make  it  a  rule  to  perform  an  iridectomy  in 
all  cases  where  they  cannot  satisfactorily  repose  the  iris  after 
delivery  of  the  lens,  but  even  where  they  can  repose  it  well,  they 
are  not,  they  state,  secure  against  the  occurrence  of  a  prolapse 
within  the  first  two  or  three  days  after  the  operation  ;  nor  do 
they  find  that  eserine,  or  any  other  means,  provides  the  desired 
safeguard.  It  is  admitted  that  prolapse  of  the  iris  takes  place 
after  a  number  of  these  operations,  and  that  there  is  no  means  of 
foretelling  in  what  eyes  it  will  occur.  The  prolapsed  portion  of 
iris  heals  in  the  wound,  which  then,  in  a  few  weeks,  becomes 


■^  Known  now  very  generally  as  The  Simple  Method,  while  the  opera- 
tion combined  with  an  iridectomy  is  now  commonly  termed  The  Combined 
Method. 


344  DISEASES   OF   THE   EYE. 

more  or  less  cystoid  and  bulging,  causing  displacement  of  the 
pupil  and  irregular  curvature  of  the  cornea,  with  resulting 
deterioration  of  vision.  Nor  is  this  all,  for  such  eyes  are  liable, 
weeks,  months,  or  even  years  after  the  operation,  to  take  on 
severe  irido-cyclitis,  ending  in  total  loss  of  sight.  Another  dis- 
advantage of  this  operation  is,  that  removal  of  cortical  remains 
cannot  be  so  effectually  performed  as  where  acoloboma  has  been 
made. 

Therefore,  while  admitting  the  charm  of  a  circular  pupil,  I  am 
of  opinion  that  the  question  is  not  whether  the  appearance  of 
some  of  the  eyes  operated  on  is  pleasing  to  us,  and  to  others  who 
inspect  them,  but,  rather,  what  advantage  the  greatest  number  of 
persons  operated  on  derive  from  the  operation.  With  sentimental 
talk  about  "  mutilation  "  of  the  iris  I  cannot  pretend  to  sympa- 
thize. If  the  advocates  of  the  method  under  discussion  should 
find  a  means  of  insuring  the  eye  against  prolapse  of  the  iris,  the 
operation  will  be  placed  upon  a  different  footing,  but  until  then 
the  procedure  cannot,  I  think,  be  recommended. 

It  is  easy  to  understand  why,  in  the  simple  extraction,  pro- 
lapse of  the  iris  with  subsequent  incarceration  is  so  liable  to 
occur,  even  some  days  after  the  operation,  and  why  it  is  so  diffi- 
cult to  devise  a  sure  means  for  preventing  the  accident;  as,  also, 
how  it  is  that  even  a  very  narrow  coloboma  is  sufficient  to 
protect  the  eye  from  this  disaster.  And  yet  I  am  inclined  to 
think  that  among  those  oculists  who  have  reverted  to  the  simple 
method  there  are  some  who  do  not  realize  the  modus  operandi  in 
either  case.  Within  a  few  hours  after  the  operation  the  wound 
in  the  corneal  margin  most  commonly  closes,  the  aqueous  humor 
collects,  and  the  anterior  chamber  is  restored.  But  it  takes  many 
hours  more  for  the  delicate  union  of  the  lips  of  the  wound  to 
become  quite  consolidated,  and  during  this  time  it  requires  but 
little — a  cough,  a  sneeze,  a  motion  of  the  head,  the  necessary 
efforts  in  the  use  of  a  urninal  or  bed-pan,  no  matter  how  careful 
the  nursing — to  rupture  the  newly  formed  union,  and,  as  a  matter 
of  fact,  this  often  does  take  place.  The  aqueous  humor  then 
flows  away  through  the  wound  with  a  sudden  gush,  and,  where 


THE    CRYSTALLINE    LENS.  345 

the  simple  extraction  has  been  employed,  carries  with  it  the  iris. 
Doubtless,  in  this  event,  it  is  that  portion  of  the  aqueous  humor 
which  is  situated  behind  the  iris,  which  is  chiefly  concerned  in 
the  iris-prolapse;  the  aqueous  humor  in  the  anterior  part  of  the 
anterior  chamber  probably  flows  off"  without  influencing  the 
position  of  the  iris.  The  advocates  of  the  simple  operation  en- 
deavor to  prevent  secondary  iris-prolapse  by  a  spastic  contraction 
of  the  pupil,  produced  by  eserine,  which  is  instilled  at  the  con- 
clusion of  the  operation,  and  again,  by  some  operators,  a  few 
hours  afterward.  In  most  instances  the  desired  end  is  by  this 
means  efl^ected.  But  there  is  a  considerable  percentage  of  the 
cases  in  which  the  contraction  of  the  sphincter  iridis  is  overcome 
by  the  pressure  of  the  aqueous  humor  from  behind,  and  iris- 
prolapse  takes  place. 

How,  then,  does  the  formation  of  a  coloboraa  prevent  prolapse 
of  the  iris,  when  the  wound  bursts,  as  I  have  described  ?  Not 
because  the  portion  of  iris  which  is  liable  to  prolapse  has  been 
taken  away.  That  would  mean  nothing  less  than  the  whole  of 
that  part  of  the  iris  which  corresponds  to  the  length  of  the  open- 
ing in  the  corneal  margin.  But  the  coloboma  averts  secondary 
iris-prolapse,  because  it  provides  a  gateway,  a  sluice,  for  the 
aqueous  humor  contained  in  the  posterior  part  of  the  anterior 
chamber  to  escape  directly  through  the  wound,  without  carrying 
with  it  the  iris  in  its  rush ;  and  it  is  evident  that  the  narrowest 
coloboma  which  can  be  formed  will  be  amply  sufficient  for  the 
purpose.  To  my  mind  a  narrow  iridectomy  here  is  no  "mutila- 
tion of  the  iris,"  but  rather  a  measure  which  rests  upon  a  sound 
scientific  basis,  and  which  is  calculated  to  ensure  the  safety  of  the 
eye  in  an  important  particular. 

As  to  disfigurement  of  the  eye,  there  is  practically  none  when 
the  coloboma  is  so  narrow  and  is  situated  in  the  upper  part  of 
the  iris.  The  pupil,  too,  is  movable,  almost,  if  not  quite  as  much 
so,  I  venture  to  say,  as  in  most  cases  of  simple  extraction.  For 
it  is  entirely  a  mistake  to  suppose  that  a  narrow  coloboma  renders 
the  pupil  immovable.  Where  there  are  no  adhesions  between 
the  pupillary  margin  and  the  capsule,  as  frequently  happens,  the 


346  DISEASES   OF   THE    EYE. 

reaction  to  light  is  active,  a  drop  of  atropine  will  dilate  the  pupil 
widely,  and  a  drop  of  eserine  will  contract  it. 

Mental  Derangements  after  Cataract  Extractions. — After  cata- 
ract extractions,  during  the  period  of  confinement  to  bed,  passing 
mental  disturbances  are  sometimes  seen  in  old  people.  This 
usually  takes  the  form  of  confusion  of  ideas,  hallucinations,  and 
terror.  It  is  hard  to  assign  a  cause  for  it,  but  probably  it  is 
mainly  due  to  the  quiet  and  the  exclusion  of  light,  following  on 
a  period  of  some  anxiety  and  excitement.  A  few  doses  of  sul- 
phonal  and  permission  to  sit  up — at  least  in  bed — with  the 
admission  of  more  daylight,  will  be  the  best  measures  to  adopt 
in  such  a  case;  and  speedy  restoration  of  mental  equilibrium 
may  be  looked  for  with  confidence.  Care  should  be  taken  not 
to  mistake  the  symptoms  of  atropine  poisoning  for  this  form  of 
mental  disturbance. 

Secondary  Glaucoma  after  Cataract  Extraction  occurs  now  and 
then,  by  whatever  method  the  extraction  may  have  been  per 
formed.  This  is  contrary  to  what  one  would  have  expected,  in 
view  of  the  diminished  contents  of  the  globe,  by  reason  of 
absence  of  the  lens,  and  especially  in  those  cases  where  an  iri- 
dectomy has  been  made.  High  tension  in  these  instances  may 
come  on  soon  after  recovery  from  the  cataract  operation,  or  after 
a  good  result  has  existed  for  many  years.  Treacher  Collins'  * 
and  Natanson's  f  microscopic  investigations  show  that  in  these 
cases  either  the  iris,  the  capsule,  or  the  hyaloid,  has  become  en- 
tangled in  the  wound,  and  it  seems  that  this  leads  in  some  cases 
to  closure  of  the  filtration  angle  in  its  entire  circumference;  but, 
obviously,  further  information  is  required  on  this  rather  obscure 
(question. 

A  wide  iridectomy,  or  a  sclerotomy,  should  be  made  as  soon 
as  possible  after  the  high  tension  shows  itself,  and  by  this  means 
many  of  these  eyes  may  be  saved. 

Discission  or  Dilaceration  means  the  tearing  of  the  anterior 


*  Trans.  Ophth.  Sac,  vol.  x,  p.  108. 

t  "Ueber  Glaucom  in  Aphakischen  Augen."     Dorpat,  1889. 


THE   CRYSTALLINE    LENS.  347 

capsule  of  the  lens  with   a   needle,  so  as  to  give   the  aqueous 
humor  access  to  the  lenticular  fibres,  which  causes  them  to  swell, 
and  gradually  to  become  soft,  and  then  to  be  absorbed. 
The  larger  the  capsular  opening,  the  more  freely  is  the     ^^' 
aqueous    brought   in    contact   with    the    lens,   and   the 
more  rapid  is  its  swelling.     The  rapidity  of  the  swell- 
ing and  absorption  depend,  also,  on  the  consistence  of 
the  lens.     The  softer  it  is,  the  more  rapid  is  the  pro- 
cess,  the    completion    of    which    may    require   from    a 
few  weeks  to  many  months.     It  is    wise   to  make  the 
first  discission  of  moderate  dimensions,  in  order  to  test 
the  irritability  of  the  eye,  especially  in  adults. 

The  instruments  required  are  a  spring  speculum, 
a  fixation  forceps,  and  a  Bowman's  stop-needle  (Fig. 
122).  The  shoulder  on  the  latter  instrument  prevents 
its  advance  too  far  into  the  eye.  The  pupil  is  to  be 
dilated  with  atropine. 

The  eye  having  been  cocainized,  the  speculum  applied, 
and  the  eye  fixed  close  to  the  inner  margin  of  the  cornea, 
the  needle  is  passed  perpendicularly  through  the  cornea 
in  its  lower  and  outer  quadrant,  at  a  point  correspond- 
ing to  the  margin  of  the  dilated  pupil.  It  is  then  ad- 
vanced upward  to  the  upper  margin  of  the  pupil  (Fig. 
123),  where  it  is  passed  into  the  capsule,  but  not  deeply 
into  the  lens,  and  a  vertical  incision  is  effected  by  with- 
drawing the  instrument  slightly.  If  an  extensive  open- 
ing in  the  capsule  be  wished  for,  a  horizontal  incision 
can  be  added  to  the  vertical  by  a  corresponding  motion 
of  the  needle.  During  these  manoeuvres,  the  cornea,  at 
the  point  of  puncture,  must  form  the  fulcrum  for  the 
motions  of  the  instrument.  The  instrument  is  then 
withdrawn  and  some  aqueous  humor  escapes  through 
the  opening.  Atropine  is  instilled  and  the  bandage 
applied.  The  patient  is  kept  in  bed,  in  a  darkened  '\]J 
room,  for  a  day,  and  then  the  bandage  may  be  dispensed 
with  and  dark  spectacles  worn.     The  iris  is  to  be  kept  well  under 


348 


DISEASES   OF   THE   EYE. 


the  influence  of  atropine  until  tlie  absorption  of  the  lens  is  com- 
pleted. Repetition  of  the  operation  is  called  for  if  the  opening 
be  so  small  as  to  admit  of  but  a  very  slow  absorption  of  the 
lens,  or  if,  as  sometimes  happens,  the  opening  should  become 
closed  up. 

This  method  is  applicable  to  all  complete  cataracts  up  to 
the  twenty-fifth  year  of  age,  and  to  those  lamellar  cataracts  in 
which  the  opacity  approaches  so  close  to  the  periphery  of  the 
lens  that  nothing  can  be  gained  by  an  iridectomy.  After  the 
above  age  the  increasing  hardness  of  the  nucleus  and  the  in- 
creasing irritability  of  the  iris  render  the  method  unsuitable. 

Discission  is  a  safe  pro- 
FiG.  123.  cedure  when  used  with  the 

above  indications  and  pre- 
cautions.    The    danger 
chiefly  to  be  feared  is  iritis, 
from   pressure  on  the  iris 
of  the  swelling  lens  masses. 
When    this   occurs,    or    is 
threatened,  removal  of  the 
cataract  by  a  linear  inci- 
sion in  the  cornea  should 
be  at  once  performed.     A 
safeguard      against     iritis 
may  be  had  in  a  preliminary  iridectomy  (von  Graefe),  and  it 
is,  perhaps,  well  to  do  this  in  all  cases  over  fifteen  years  of  age, 
the  discission  following  some  weeks  afterward. 

Another  danger  consists  in  glaucomatous  increase  of  tension 
(secondary  glaucoma),  which  may  come  on  without  any  subjec- 
tive symptoms,  while  the  absorption  of  the  lens  runs  its  proper 
course.  It  may  happen,  in  this  way,  that  when  absorption  of  the 
cataract  is  completed,  the  eye  will  be  found  blind  from  glaucoma. 
Frequent  testings  of  the  tension  of  the  eye  during  the  cure  are, 
therefore,  a  most  important  precaution.  Should  the  tension  rise, 
removal  of  the  lens  through  a  linear  incision  in  the  cornea  is  at 
once  indicated ;  or,  the  suction  operation  may  be  employed. 


THE   CRYSTALLINE   LENS.  349 

Suction  Operation  of  Cataract. — This  method  can  only  be  used 
for  semi-fluid  or  soft  cataracts. 

The  pupil  having  been  well  dilated  with  atropine,  and  the  eye 
cocainized,  a  free  opening  is  made  in  the  capsule  of  the  lens 
with  a  discission  needle.  A  linear  incision  is  then  made  in  the 
cornea  about  half  way  between  its  centre  and  its  margin,  and  the 
point  of  a  Bowman's  or  a  Teale's  syringe  introduced  through  it, 
and  through  the  opening  in  the  capsule,  into  the  substance  of  the 
lens.  Gentle  suction  is  then  applied,  and  the  lens  substance 
drawn  into  the  syringe.  The  syringe  should  not  be  passed  be- 
hind the  iris.  If  it  be  thought  that  the  cataract  is  not  suffi- 
ciently soft,  it  is  desirable  to  allow  some  time  (a  fortnight  or  so) 
to  elapse  between  the  discission  and  the  suction,  in  order  that  the 
lens  substance  may  undergo  disintegration  by  the  action  of  the 
aqueous  humor. 

Secondary  Cataract  and  its  Operation — Capsulotomy.— The 
term  "secondary  cataract,"  as  here  used  (compare  p.  319),  usu- 
ally means  a  closure  of  the  opening  in  the  anterior  capsule  left 
after  the  removal  of  a  cataractous  lens,  with  sometimes  a  thick- 
ening of  the  capsule,  by  which  an  impediment  is  offered  to  the 
rays  of  light  in  passing  through  the  pupil.  The  thickening  may 
have  pre-existed  in  the  capsule,  or  it  may  be  due  to  subsequent 
proliferation  of  the  epithelial  cells  on  the  inner  surface  of  the 
capsule.  The  term  is  also  used  with  reference  to  those  cases  in 
which  no  central  opening  has  been  made  in  the  capsule  (peri- 
pheral capsulotomy),  and  where  the  latter  causes  imperfect  vis- 
ion. It  is  also  used  in  those  cases  where,  after  cataract  extrac- 
tion, an  exudation  in  the  pupil,  consequent  upon  iritis,  has 
occurred.  And  finally,  it  is  applied  to  the  cases  which  Fig.  121 
represents,  in  which,  after  suppuration  of  the  wound  with  irido- 
cyclitis, the  iris  is  dragged  upward,  and  the  pupil  consequently 
obliterated. 

The  most  simple  form  of  secondary  cataract  occurs  as  a  very 
fine  cobweb-like  membrane,  extending  over  the  whole  area  of  the 
pupil,  which  can  often  only  be  discovered  by  careful  examina- 
tion with  oblique  illumination.     It  may  not  appear  until  some 


350 


DISEASES    OF    THE    EYE. 


months  after  the  extraction,  and  then  causes  the  patient  to  com- 
plain of  diminished  acuteness  of  vision.  It  is  a  simple  matter 
to  make  a  rent  in  this  delicate  membrane  with  a  discission 
needle. 

Where  there  are  thick  opacities  in  the  capsule  or  inflammatory 
exudation  into  the  pupil,  with,  probably,  adhesions  of  the  iris  to 
the  pupillary  membrane,  extraction  of  the  latter  has  been  pro- 
posed and  practiced,  but  is  associated  with  so  much  danger,  from 
the  unavoidable  dragging  on  the  ciliary  body  and  iris,  that  the 
proceeding  is  not  often  employed. 

Fig.  124. 


Sir  W.  Bowman's  Method  with  two  needles  is  here  much  prefer- 
able. In  it  the  point  of  a  discission  needle  is  passed  through  the 
inner  quadrant  of  the  cornea  and  into  the  centre  of  the  opacity 
(Fig.  124),  and  then,  with  the  other  hand,  a  second  needle  is 
passed  through  the  outer  quadrant  of  the  cornea  and  into  the 
membrane,  close  beside  the  first  needle.  The  points  of  the 
needles  are  now  separated  from  each  other  by  approximation  of 
their  handles,  and  in  this  way  a  hole  is  made  in  the  membrane. 
A  very  small  opening  in  the  capsule,  if  quite  clear,  is  sufficient 
to  establish  good  vision. 


THE    CRYSTALLINE    LENS.  351 

Dr.  Xoyess  Method.'^ — A  Graefe's  cataract-knife  is  entered  in 
the  horizontal  meridian  of  the  cornea  at  its  temporal  margin, 
and  a  counterpuncture  made  in  the  same  meridian  at  the  inner 
corneal  margin.  The  point  of  the  knife  is  now  withdrawn  into 
the  anterior  chamber,  and  made  to  puncture  the  secondary 
cataract,  and  is  then  removed  from  the  eye.  Two  blunt-pointed 
hooks  are  then  entered  into  the  anterior  chamber,  one  through 
each  corneal  puncture,  and  the  point  of  each  passed  through  the 
opening  in  the  membrane  made  with  the  knife.  By  traction  on 
the  hooks  this  opening  is  enlarged  without  any  dragging  on  the 
iris  or  ciliary  body. 

Tridotomy. — For  the  cases,  as  in  Fig.  121,  where  the  iris  forms 
a  complete  and  tightly  stretched  curtain  across  the  pupil,  iridec- 
tomy is  the  operation  which  readily  suggests  itself.  In  very  few 
cases,  however,  does  it  give  a  satisfactory  result,  owing  to  the 
inflammatory  products  which  lie  behind  the  iris  and  which  close 
up  any  artificial  pupil  by  their  proliferation,  which  is  set  going 
by  the  dragging  of  the  iris  with  the  forceps.  Repeated  iridec- 
tomies may  finally  produce  a  clear  pupil,  but  iridotomy,  in  which 
there  is  no  dragging  of  the  iris,  is  a  better  operation  in  these 
cases. 

There  are  several  modes  of  performing  iridotomy,  that  of 
de  Wecker  being  the  best.  A  vertical  incision  having  been 
made  in  the  cornea,  about  3  mm.  long  and  the  same  distance 
removed  from  its  inner  margin,  the  closed  blades — one  of  which 
has  a  sharp  point — of  de  Wecker's  forceps-scissors  are  passed 
into  the  anterior  chamber.  The  blades  are  then  opened  and  the 
sharp  point  of  one  of  them  is  forced  through  the  stretched  iris 
and  some  3  or  -1:  mm.  behind  it.  By  now  closing  the  blades  the 
tightened  iris  fibres  are  cut  across,  and,  on  their  retraction,  a 
central  clear  pupil  is  formed  in  the  iris  and  retro-iridic  tissue. 

Dislocation  of  the  Crystalline  Lens. — This  may  be  congenital, 
and  due  to  arrested  development  of  the  zonula  of  Zinn  ;  or  it 
may  be  the  result  of   disease,  such,  for  example,  as  anterior 


Diseases  of  the  Eye"'   (London,  1882),  p.  251. 


352  DISEASES    OF    THE    EYE. 

sclero-choroiditis ;  or  it  may  be  caused  by  a  blow,  or  other 
trauma. 

The  dislocation  may  be  partial  or  complete.  In  the  former 
case  it  is  often  so  slight  as  to  be  discoverable  only  when  the 
pupil  is  widely  dilated,  the  margin  of  the  lens  becoming  then 
visible  as  a  black  line  in  some  one  direction,  by  aid  of  the 
ophthalmoscope  mirror.  Or,  the  displacement  may  be  so  great 
as  to  bring  the  margin  of  the  lens  across  the  centre  of  the  un- 
dilated  pupil,  in  which  case  one  part  of  the  eye  will  be  highly 
hypermetropic,  while  in  another  part  it  will  be  myopic.  Com- 
plete dislocation  may  take  place  into  the  anterior  chamber,  into 
the  vitreous  humor,  and  even  under  the  conjunctiva,  if  the 
sclerotic  has  been  ruptured. 

The  symptoms  in  partial  dislocation  are  those  of  loss  of  power 
of  accommodation  and  monocular  double  vision.  Iridodonesis 
(i.  e.,  trembling  of  the  iris  when  the  eye  moves)  is  present,  as  a 
rule,  in  consequence  of  the  loss  of  support  provided  by  the  lens. 
In  complete  dislocation  the  symptoms  are  those  of  aphakia,  i.  e., 
extreme  hypermetropia  and  want  of  power  of  accommoda- 
tion. 

Treatment. — In  partial  dislocation  it  is  rarely  that  any  treat- 
ment can  be  of  service.  The  prescribing  of  spectacles  suited, 
so  far  as  is  practicable,  to  the  faulty  refraction  is  indicated.  In 
complete  dislocation  of  the  lens  into  the  anterior  chamber  its 
extraction  is  usually  required,  especially  if  it  cause  symptoms 
of  irritation.  Dislocation  into  the  vitreous  humor  is  generally 
unattended  by  irritation ;  but,  when  the  latter  does  arise,  re- 
moval of  the  lens  by  aid  of  a  spoon,  through  a  peripheral 
corneal  incision,  has  to  be  attempted. 

Lenticonus  is  a  very  rare  congenital  anomaly  of  the  lens,  in 
which  the  anterior  surface,  or,  still  more  rarely,  the  posterior 
surface,  is  cone-shaped. 

Aphakia  («,  jyriv.;  ^a/.o:;,  a  lentil,  lens),  or  Absence  of  the 
Crystalline  Lens. — The  condition  of  the  emmetropic  eye  after 
the  removal  of  a  cataract  is  one  of  high  hypermetropia,  and 
the  power  of  accommodation  is  wanting.   Consequently,  in  order 


THE   CRYSTALLINE    LENS.  353 

that  the  eye  may  have  the  best  possible  sight  for  distant 
objects,  a  high  convex  glass  has  to  be  experimentally  found  to 
suit  it,  and  stronger  lenses  must  be  prescribed  for  shorter  dis- 
tances. 

The  degree  of  vision  obtained  varies  considerably  in  different 
cases  ;  frequently  Y  =  f  is  obtained,  but  Y  =  ^  may  be  re- 
garded as  a  satisfactory  result,  and  even  lower  degrees,  which 
enable  the  patients  to  find  their  way  about  with  comfort,  are 
classed  as  successful  operations.  The  vision  often  improves  for 
some  months  after  the  operation,  patients  who  at  first  had  only 
jig  or  so  advancing  up  to  f  or  f.  For  reading,  writing,  etc.,  at 
about  25  cm.,  a  still  higher  convex  glass  must  be  provided.  If 
the  correcting  lens  for  distant  vision  be  -]-  10  D,  its  power,  for 
vision  at  25  cm.,  must  be  increased  by  the  lens  which  would  rep- 
resent the  amplitude  of  accommodation  from  infinite  distance  up 
to  25  cm.  This  lens  is  4  D  (because  ^J'-  =  4,  therefore  -|-  14 
D  is  the  lens  required.  With  these  two  lenses  most  patients  are 
satisfied.  For  distinct  vision  at  middle  distances,  they  learn  to 
vary  the  power  of  the  lenses  by  moving  them  a  little  closer  to, 
or  further  from,  the  eye  ;  but,  if  necessary,  a  lens  can  be  pre- 
scribed for  distinct  vision  at  any  desired  distance. 

In  the  case  of  hospital  patients,  one  is  often  obliged  to  select 
the  -j-  glasses  in  a  fortnight  or  three  weeks  after  the  operation, 
but  the  result  is  more  satisfactory  when  the  selection  can  be 
postponed  for  six  weeks  or  two  months.  Permanent  wearing  of 
the  -{-  glasses  should  not  be  permitted  until  all  redness  of  the 
eye  has  passed  ofl^,  and  this  varies  in  different  cases.  Until  then, 
also,  dark  protection  spectacles  should  be  worn. 

In  a  large  number  of  cases,  after  cataract  operations,  the  best 
vision  is  not  obtained  until  existing  astigmatism  is  corrected,  and 
in  ascertaining  its  degree  the  astigmometer  is  of  great  service. 
High  degrees  of  astigmatism  are  often  present  after  cataract 
operations,  in  eyes  which  previously  were  free  from  it.  This 
may  be  due  to  astigmatism  of  the  cornea  having  been  formerly 
compensated  by  an  opposite  form  of  astigmatism  of  the  lens ;  or, 
it  may  be  the  result  of  cicatrical  contraction  of  the  corneal 
30 


354  DISEASES   OF   THE   EYE. 

wound.  The  astigmatism  here  is  usually  "  against  the  rule  "  (see 
p.  39),  and  greater  for  some  weeks  after  the  operation  than  later 
on,  and  therefore  it  is  well  not  to  prescribe  cylindrical  glasses  for 
at  least  two  months  subsequent  to  the  operation. 

(For  an  account  of  Erythropsia  after  cataract  extraction  see 
Chap.  XYII.) 


CHAPTER  XIV. 
DISEASES    OF    THE   VITREOUS  HUMOR. 

Purulent  Inflammation  of  the  Vitreous  Humor  (to  which, 
unfortunately,  the  name  pseudo-glioma  is  sometimes  applied) 
occurs  only  as  the  result  of  perforating  injuries,  or  of  the 
lodgment  of  a  foreign  body,  or  as  an  extension  of  a  purulent 
process  from  the  choroid  (p.  253).   . 

Ophthalmoscojncally,  a  purulent  deposit  in  the  vitreous  humor 
gives  a  yellowish  reflection.  It  is  to  be  distinguished  from  a 
somewhat  similar  appearance  in  glioma  of  the  retina  by  the 
history,  by  its  early  complication  with  more  or  less  severe 
iritis,  by  the  very  frequent  retraction  of  the  periphery  of  the 
iris,  with  bulging  forward  of  its  pupillary  part,  and  by  the 
diminished  tension  of  the  eye,  while  a  lobulated  appearance 
is  not  so  usual  in  it  as  in  glioma.  Again,  in  glioma  the 
vitreous  humor  remains  clear,  while  in  this  disease  it  is  hazy. 

The  condition,  if  at  first  confined  to  the  vitreous  humor, 
soon  extends  to  the  surrounding  tissues,  and  usually  leads  to 
panophthalmitis  and  complete  destruction  of  the  eye. 

Inflammatory  Aff'ections  of  the  Vitreous  Humor,  other  than 
the  purulent  form,  are,  for  the  most  part,  the  consequence 
of  diseases  of  the  choroid,  ciliary  body,  or  retina,  and  display 
themselves  as  opacities  of  various  kinds.  These  either  are 
cells  derived  from  the  primarily  diseased  tissue,  or  they  are 
secondary  changes  (connective  tissue  development),  the  result 
of  this  cellular  invasion. 

The  chief  Varieties  of  Vitreous  Humor  Opacities  are:  1. 
The  Dust-like  Opacity  so  characteristic  of  syphilitic  disease 
of  the  retina  and  choroid.  It  may  occupy  the  entire  vitreous 
humor,  but  is  frequently  confined  to  the  region  of  the  ciliary 
body,  or  to  that  of  the  posterior  layers  of  the  vitreous  humor 

355 


356  DISEASES   OF   THE   EYE. 

2.  Flakes  and  Threads.  These  occur  with  chronic  affections 
of  the  choroid  or  ciliary  body,  and  may  be  the  result  also 
of  hemorrhages  into  the  vitreous  humor.  They  invade  every 
portion  of  the  humor.  3.  Membranous  Opacities,  which 
are  rare,  and  are  probably  the  result  either  of  extensive 
hemorrhagic  extravasations  or  of  choroidal  exudations. 

Hemorrhages  into  the  vitreous  humor  are  not  uncommon, 
and  are  the  result  of  certain  diseases  of  the  retina  and  choroid, 
which  are  accompanied  by  hemorrhages  in  those  membranes. 
They  are  also  caused  by  blows  on  the  eye  which  rupture 
the  choroidal  or  retinal  vessels.  Most  of  the  alterations 
occurring  in  the  vitreous  humor  are  attended  with,  or  give 
rise  to,  fluidity  of  it. 

The  Diagnosis  of  opacities  in  the  vitreous  humor  is  made 
with  the  ophthalmoscope  mirror  and  a  not  very  bright 
light,  or  with  the  plane  mirror.  If  a  very  bright  light  and 
concave  mirror  be  employed,  the  finer  opacities  will  not  be 
readily  seen.  The  pupil  being  illuminated,  the  patient  is 
directed  to  look  rapidly  in  different  directions,  when  the 
opacities  will  be  seen  to  float  across  the  area  of  the  pupil, 
as  they  are  thrown  from  one  side  of  the  eye  to  the  other. 

Another  and  very  fine  method  for  the  detection  of  delicate 
opacities  in  the  vitreous,  is  by  placing  a  high  -f-  lens,  say 
-\-  10  D,  behind  the  ophthalmoscope  mirror,  and  then  going 
close  to  the  eye,  as  in  the  examination  of  the  upright  image. 
Minute  opacities  will  then  be  seen  as  black  dots  floating 
in  the  vitreous  humor. 

The  ophthalmoscope  does  not  always  detect  changes  in  the 
choroid  or  retina  when  there  are  opacities  in  the  vitreous;  and, 
in  many  such  cases,  we  are  led  to  the  belief  that  the  diseased 
changes  in  the  choroid  or  retina  are  too  fine  to  be  seen  with 
the  ophthalmoscope,  or  that  they  are  situated  in  the  region 
of  the  ciliary  body  which  is  out  of  view. 

Vision  is  affected  by  opacities  in  the  vitreous  humor  in  propor- 
tion to  their  density,  and  to  the  extent  to  which  the  vitreous 
humor  is  occupied  by  them.     The  patients  often  observe  them  as 


THE   VITREOUS   HUMOR.  357 

floating  positive  scotomata  in  their  field  of  vision.  These  *'  en- 
toptic  appearances  "  are  caused  by  the  shadows  of  the  opacities 
thrown  on  the  retina. 

The  Prognosis  depends  on  the  cause  of  the  opacities.  Small 
hemorrhagic  extravasations  in  young  people  are  readily  absorbed. 
The  dust-like  opacity  of  specific  retinitis  is  also  favorable  for 
absorption,  while  extensive  hemorrhages  in  older  people,  and 
the  "  flake  and  thread  "opacities,  frequently  remain  as  permanent 
obstructions.  Moreover,  by  shrinking,  many  of  the  more  organ- 
ized opacities  give  rise  to  detachment  of  the  retina  from  the 
choroid,  and  consequent  blindness. 

Treatment  consists,  above  all,  in  that  for  the  exciting  cause. 
Besides  this,  Heurteloup's  artificial  leech,  or  dry  cupping  on  the 
temple,  is  most  useful ;  and  in  many  cases,  soon  after  the  applica- 
tion, a  marked  clearing  up  of  the  vitreous  is  apparent.  Pilo- 
carpine hypodermically  is  worthy  of  trial.  In  one  case  von 
Graefe  operated  on  membranous  opacities  by  tearing  them 
with  a  needle,  and  with  a  successful  result. 

Mouches  Volantes,  Muscae  Volitantes,  and  Myodesopsia 
QiuTa^  afly;  oiptq,  seeing) ,  are  terms  applied  to  the  motes  which 
people  frequently  see  floating  before  their  eyes,  but  which  do 
not  interfere  with  the  acuteness  of  vision,  nor  can  the  ophthal- 
moscope detect  opacities  in  the  vitreous  humor,  or  any  other 
intraocular  disease.  These  motes  are  most  apparent  when  a 
bright  surface,  such  as  a  white  wall  or  field  of  a  microscope,  is 
looked  at.  Mouches  volantes  have  no  clinical  importance. 
Those  annoyed  with  them  should  be  strongly  recommended  not 
to  look  for  them,  as  in  that  case  others  are  very  apt  to  become 
visible.  They  depend,  probably,  upon  minute  remains  of  the 
embryonic  tissue  in  the  vitreous  humor. 

Fluidity  of  the  Vitreous  Humor,  or  Synchysis  (tuv,  together ; 
yjio^  to  pour),  is  not  rare.  It  can  only  be  diagnosed  with  certainty 
when  the  humor  contains  floating  opacities.  Low  tension  of  the 
eyeball  does  not  always  indicate  fluidity  of  the  vitreous,  although 
soft  eyeballs  nearly  always  contain  fluid  vitreous  humor.  Trem- 
bling of  the  iris  is  also  no  sign  of  fluid  vitreous,  but  merely 


358  DISEASES   OF   THE   EYE. 

indicates  that  the  iris  is  not  supported  in  the  normal  way  by  the 
crystalline  lens.  Defective  zonula  of  Zinn,  however,  is  often 
caused  by,  or  is  a  concomitant  of,  fluid  vitreous,  and  by  causing 
displacement  of  the  lens,  would  allow  of  trembling  of  the  iris. 
The  Causes  of  synchysis  are  choroiditis  and  staphyloma  of  the 
choroid  and  sclerotic,  and  it  also  occurs  as  a  senile  change. 

Synchysis  Scintillans  is  a  fluid  condition  of  the  vitreous  humor, 
with  cholesterine  and  tyrosine  crystals  held  in  suspension  in  it. 
The  ophthalmoscopic  appearances  are  very  beautiful,  resembling 
a  shower  of  golden  rain.  A  satisfactory  explanation  for  the 
occurrence  of  these  crystals  in  this  position  has  not  yet  been 
given.  They  usually  occur  in  old  people,  and  seldom  cause  any 
marked  deterioration  of  vision. 

Fluidity  of  the  vitreous  humor  is  not,  per  se,  a  condition  of 
serious  import,  unless  the  eye  come  to  be  the  subject  of  an 
operation  involving  an  incision  in  the  corneo-sclerotic  coat,  when 
it  renders  prolapse  of  the  vitreous  more  liable  to  take  place. 

Foreign  Bodies  in  the  Vitreous  Humor. — One  of  the  most 
common  accidents  to  the  eye  is  perforation  of  the  sclerotic,  or 
of  the  cornea  and  crystalline  lens,  by  a  small  foreign  body  (shot, 
morsel  of  iron,  copper,  stone,  or  glass),  which  then  lodge  in  the 
vitreous  humor. 

In  cases  where  the  ophthalmoscope  fails  us,  owing  to  extrava- 
sation of  blood,  etc.,  it  is  sometimes  not  easy  to  say  whether  the 
foreign  body  be  in  the  eye,  or  whether  it  may  merely  have  punc- 
tured the  sclerotic  and  fallen  to  the  ground.  If  it  be  known  to 
have  been  a  small  foreign  body,  which  has  flown  against  the  eye 
with  force,  the  probabilities  are  that  it  is  lodged  in  the  eye. 

But  if  the  case  be  brought  immediately,  or  soon  after  the 
accident,  and  there  be  no  intraocular  hemorrhage  to  obscure  our 
view,  the  foreign  body  may  frequently  be  detected  with  the 
ophthalmoscope  in  the  vitreous  humor  as  a  dark  or  glittering 
body,  according  to  its  nature.  And  focal  illumination  with 
dilated  pupil  will  often  help  us  to  discover  a  foreign  body  situ- 
ated in  the  anterior  part  of  the  vitreous  humor.  Or  if  it  cannot 
be  seen,  an  opaque  streak  through  the  vitreous  humor,  one  end 


THE    VITREOUS    HUMOR.  359 

of  which  corresponds  with  the  sclerotic  wound,  may  indicate  the 
track  taken  by  a  foreign  body. 

In  case  the  foreign  body  has  perforated  the  cornea  and  reached 
the  vitreous  humor  through  the  circumlental  space,  a  counter- 
opening  will  be  found  in  the  iris,  while  if  it  be  supposed  to  have 
passed  through  the  cornea  and  lens,  the  openings  both  in  the 
anterior  and  posterior  capsule  of  the  lens  should  be  sought  for. 

It  is  rarely  that  a  foreign  body,  whether  it  remain  free,  or,  as 
sometimes  happens,  become  encapsuled,  is  tolerated  permanently 
in  any  part  of  the  interior  of  the  eye,  and  the  event  should  never 
be  calculated  on  in  the  treatment  of  such  a  case. 

As  a  rule,  foreign  bodies  in  the  vitreous,  as  elsewhere  within 
the  eye,  soon  produce  violent  inflammatory  reaction.  This 
occurs  either  by  reason  of  infective  micro-organisms  being  intro- 
duced into  the  eye  with  the  foreign  body,  or  it  may  be  caused  by 
the  oxidization  of  the  foreign  body,  when,  as  is  most  common,  it 
is  of  iron  or  copper.  The  form  of  inflammation  may  be  either  a 
plastic  or  purulent  uveitis,  in  the  latter  case  with  purulent  infil- 
tration of  the  vitreous  humor  and  hypopyon. 

An  eye  which  contains  a  foreign  body  that  is  not  or  cannot 
be  at  once  removed,  may  be  regarded  as  lost ;  and  such  an  eye 
becomes,  moreover,  one  of  the  surest  sources  of  sympathetic 
ophthalmitis. 

It  is,  consequently,  of  the  utmost  importance  to  remove  every 
foreign  body  from  the  interior  of  the  eye  if  possible,  and  with  the 
least  delay ;  or,  if  not,  carefully  to  watch  the  eye,  and  at  any 
sign  of  inflammatory  reaction  to  remove  the  eyeball.  Indeed,  in 
view  of  the  fact  that  this  inflammatory  reaction  almost  invariably 
comes  on  sooner  or  later,  I  should  be  inclined  to  remove  most  of 
these  eyes  at  once,  when  the  foreign  body  cannot  be  extracted. 

Removal  of  the  Foreign  Body  is  often  an  extremely  difficult 
and  disappointing  undertaking,  but  it  should  always  be  at- 
tempted when,  being  neither  steel  nor  iron,  it  is  visible  within 
the  eye,  so  that  its  position  can  be  determined  with  the  ophthal- 
moscope or  by  focal  illumination.  The  introduction  of  the 
magnet  for  the  removal  of  fragments  of  the  two  metals  named 


360  DISEASES   OF   THE    EYE. 

has  made  it  unnecessary  that  they  should  in  every  case  be  visible, 
although  here  too  the  chances  of  success  are  much  enhanced  if 
the  foreign  body  can  be  accurately  localized.  In  all  these 
operations  it  is  necessary  that  the  patient  should  be  deeply  under 
the  influence  of  an  anaesthetic,  in  order  that  as  little  vitreous 
huDQor  as  possible  may  be  lost.  And  again,  strict  antiseptic 
measures  must  be  observed,  lest  by  our  operation  the  very  form 
of  mischief  be  produced  which  it  is  our  desire  to  avert. 

There  are  several  methods  of  proceeding.  Atoms  of  glass, 
copper,  stone,  etc.,  may  sometimes  be  removed  through  an 
incision  in  the  sclerotic  which  is  either  an  enlargement  of  the 
opening  made  by  the  foreign  body,  or  is  a  special  one,  at  a  point 
more  clearly  corresponding  to  the  actual  position  of  the  latter  in 
the  eye.  This  incision  should  lie  between  two  recti  muscles, 
should  have  an  antero-posterior  direction,  and  in  order  that  it 
may  gape  but  little,  should  be  a  puncture  with  a  broad  keratome. 
Prolapse  of  the  vitreous  is  then  produced  by  pressure  on  the 
eyeball,  and  the  foreign  body  is  evacuated. 

This  method  should  only  be  tried  when  the  foreign  body  is 
situated  in  the  periphery  of  the  vitreous,  and  toward  the  equator 
of  the  eye,  where  the  opening  for  its  exit  can  be  made  in  its 
immediate  neighborhood  ;  but  the  proceeding  is  often  attended 
with  disappointment,  much  vitreous  being  lost,  while  the  foreign 
body  remains  in  the  eye. 

Or,  a  forceps  is  passed  in  through  the  opening,  and  while  the 
foreign  body  is  kept  in  view  with  the  ophthalmoscope,  it  is 
seized  and  drawn  out.  This  plan  is  also  unsatisfactory,  as,  loss 
of  vitreous  occurring,  the  cornea  becomes  flaccid,  and  the  view 
of  the  foreign  body  is  soon  obscured. 

Again,  some  surgeons  prefer  to  make  their  opening  not  close 
to  the  foreign  body,  but  exactly  at  the  opposite  side  of  the  eye- 
ball, by  which  means  they  can  often  reach  the  foreign  body  with 
greater  ease,  and  with  less  injury  to  the  tissues. 

The   magnet,  thanks  to   M'Keown,  of  Belfast,*  has  of  late 

*  Brit.  Med.  Journal,  1874,  vol.  i,  p.  800,  and  elsewhere. 


THE    VITREOUS    HUMOR.  361 

years  come  into  use  for  the  removal  of  fragments  of  steel  and 
iron  from  the  interior  of  the  eye,  and  especially  from  the 
vitreous  humor.  Electro-magnets  are  those  now  employed  for 
this  purpose,  the  instruments  of  Hirschberg"^  and  of  Simeon 
Snellt  being  the  most  suitable.  Fig.  125  represents  Mr.  Snell's 
instrument  in  two-thirds  its  actual  size.  It  is  a  core  of  soft  iron, 
around  which  is  placed  a  coil  of  insulated  copper  wire,  the 
whole  enclosed  in  an  ebonite  case.  To  one  end  of  the  instru- 
ment are  attached  the  screws  to  receive  the  battery  connections. 
At  the  other  extremity  the  core  projects  just  beyond  the  ebonite 
jacket,  and  is  tapped,  and  into  it  screws  the  needle.  Xeedles  of 
various  kinds  or  shapes  can  be  adjusted  to  the  magnet  according 

Fig.  125. 


to  the  case  to  be  dealt  with.  The  battery  used  is  a  quart 
bichromate  element.  A  needle  being  passed  through  the  scle- 
rotic opening,  is  advanced  toward  the  foreign  body,  when  the 
latter  adheres  to  it,  and  is  drawn  toward  the  wound.  Much 
care  is  required  in  drawing  it  through  the  opening,  lest  it  be 
rubbed  off  the  needle  in  its  passage.  A  forceps  is  generally 
used  at  this  part  of  the  proceeding,  either  to  dilate  the  wound, 
or  to  seize  the  foreign  body  and  extract  it. 

The  magnet  may  also  be  used  for  determining  the  presence 
of  a  fragment  of  steel  or  iron  in  the  vitreous,  if,  on  bringing 
it   close   to   the    eye,  motions  are   imparted    to   the   fragment. 

*  Centralblatt  fiir  prak.  Augenheilkunde,  1879,  p.  380. 

t  The  Electro-magnet,  etc.  (London,  1883). 

31 


362  DISEASES   OF   THE    EYE. 

T.  R.  Pooley*  made  some  very  elegant  experiments  to  ascertain 
the  presence  of  a  piece  of  steel  in  the  eye,  upon  the  principle 
that  if  a  fixed  magnet  attracts  a  movable  piece  of  steel,  a 
fixed  piece  of  steel  will  attract  a  movable  magnet.  He 
magnetized  a  sewing-needle,  and  suspended  it  by  a  fibre  of 
silk  attached  to  its  centre,  and  on  bringing  it  near  an  eye 
which  contained  an  atom  of  steel  the  needle  dipped  toward 
the  foreign  body.  Or,  if  he  magnetized  the  foreign  body  by 
passing  a  galvanic  current  through  the  eye,  the  motion  of  the 
suspended  magnet  was  even  more  decided. 

Cysticercus  in  the  Vitreous  Humor  is  not  of  rare  occurrence 
in  some  parts  of  Germany,  but  there  have  been  only  one  or  two 
such  cases  observed  in  the  British  Isles. 

The  original  seat  of  the  entozoon  is  usually  beneath  the 
retina  (see  Chap.  XV),  through  which  it  breaks  to  reach 
the  vitreous  humor,  but  it  also  sometimes  makes  its  first 
appearance  in  the  vitreous.  It  is  recognized  by  its  peculiar, 
somewhat  dumbbell  shape,  its  iridescence,  and  its  peristalic 
motions.  The  vitreous  humor  often  becomes  full  of  peculiar 
'membranous  opacities. 

Treatment. — Removal  by  operation.  The  prospects  for  the  eye 
are  very  much  worse  than  in  the  case  of  a  subretinal  cysticercus. 

Persistent  Hyaloid  Artery. — In  intra-uterine  life  the  hya- 
loid artery  is  a  prolongation  of  the  central  artery  of  the 
retina,  and  runs  from  the  papilla  to  the  posterior  surface  of 
the  crystalline  lens.  It  completely  disappears  prior  to  birth, 
except  in  those  rare  cases  where  it  remains  as  an  opaque 
string,  which  may  stretch  the  whole  way  from  papilla  to  lens, 
or  may  extend  only  part  of  the  way.  It  is  then  thrown  into 
wave-like  motions  by  the  motions  of  the  eyeball,  and  is  easily 
recognized  w^ith  the  ophthalmoscope.  It  does  not  usually 
cause  any  disturbance  of  vision. 

Detachment  of  the  Vitreous  Humor  from  the  Retina,  although 
probably  a  common  diseased  condition,  cannot  as  yet  be  recog- 

"^  Archives  of  Ophthalmology,  1880,  p.  219. 


THE   VITREOUS   HUMOR.  363 

uized  with  certaiuty  during  life,  and  rarely  becomes  the  imme- 
diate cause  of  blindness.  Its  danger  lies  in  its  liability  to  bring 
about  detachment  of  the  retina. 

Detachment  of  the  vitreous  may  be  either  idiopathic  or  due 
to  trauma.  In  the  idiopathic  cases  chronic  choroiditis  is  the 
primary  disease,  which  gives  rise  to  a  change  in  the  fine  con- 
nective tissue  elements  of  the  vitreous,  with  consequent  shrinking 
of  this  body.  Yet,  with  the  ophthalmoscope,  the  choroid  may 
seem  normal;  and,  moreover,  although  floating  opacities  may 
be  present  in  the  vitreous  chamber,  yet  it  is  quite  possible 
for  a  perfectly  clear  vitreous  to  be  detached.* 

The  condition  occurs  in  connection  with  high  degrees  of 
myopia,  where  choroiditis  is  also  common,  and  is  probably  the 
most  important  factor  in  the  production  of  the  detachment 
of  the  retina  so  frequent  in  these  eyes.  Anterior  staphyloma, 
hemorrhages  into  the  vitreous  humor,  and  neoplastic  growths 
between  the  vitreous  and  retina,  also  give  rise  to  detachment 
of  the  vitreous. 

With  regard  to  traumatic  cases,  all  perforating  injuries 
attended  with  loss  of  vitreous,  including  cataract  operations — 
and  sometimes,  when  the  wound  is  in  the  sclerotic,  without 
loss  of  vitreous — are  liable  to  be  followed  by  detachment 
of  the  vitreous. 

I  havef  recorded  a  Fig.  126. 

case  in  which  detach- 
ment of  the  vitreous 
was  the  chief  lesion 
in  the  eye,  and  was 
the  cause  of  blind- 
ness, the  vision  being 
reduced  to  perception 
of  light.  The  detachment  had  probably  been  brought  about  by 
an  idiopathic  hemorrhage  from  the  ciliary  body  into  the  ante- 


*Nordenson,  Die  Netzhautahlosiing  (Wiesbaden.  1887). 
t  Trans.  Ophthal.  Soc,  1882,  p.  41. 


364  DISEASES   OF   THE    EYE. 

rior  part  of  the  vitreous.  It  lay  (Fig.  126)  immediately  behind 
the  lens,  and  in  contact  with  it,  and  presented  the  appearance 
of  a  grayish  opacity,  much  like  a  detached  retina,  but  for  the 
absence  of  retinal  vessels.  Suspicion  of  an  intraocular  tumor 
existing,  the  eye  was  removed.  The  vitreous  lay  against  the 
ciliary  body  and  lens,  while  the  vitreous  chamber  was  filled 
with  serous  fluid,  and  the  retina  was  in  its  normal  position.  In 
the  retina  toward  the  ora  serrata  there  were  a  few  minute 
hemorrhages. 


CHAPTER  XV. 

DISEASES    OP    THE   RETINA. 

Purulent  Retinitis  is  observed  as  the  result  of  septic  embolism 
of  the  retinal  arteries  in  septicaemia  after  surgical  operations, 
etc.,  and  very  frequently  in  cases  of  metria,  and  it  is,  in  the 
latter  condition,  a  fatal  sign. 

In    an   early   stage,  the   Ophthalmoscope  shows   a  number  of 
small  hemorrhages  in  the  retina,  with  general  cloudiness  of  the 
retinal   tissues,  while  the  actual  embolisms,  which  are  usually 
multiple,  may  not  be  visible. 

The  inflammation  makes  rapid  progress,  soon  destroying 
sight,  and  extending  to  the  choroid,  iris,  and  vitreous  humor, 
until  finally  panophthalmitis  is  reached.  The  retina  is  some- 
times alone  the  primary  seat  of  the  embolic  attack,  and  some- 
times the  choroid  is  also  involved.  The  embolisms  are  often 
little  more  than  masses  of  micrococci. 

The  retina  becomes  secondarily  implicated  in  many  purulent 
processes  which  commence  in  other  parts  of  the  eye. 

Hemorrhagic  Retinitis. — In  this  affection  the  retina  contains 
a  number  of  small  hemorrhages.  They  occur  chiefly  between 
the  fibres  of  the  inner  layer,  and  consequently  present  a  flame- 
like appearance  as  seen  with  the  Ophthalmoscope.  Any  which 
lie  in  the  outer  layers  are  most  apt  to  be  round  or  irregular  in 
shape.  In  addition  to  the  hemorrhages,  there  is  diff*use  opacity 
of  the  retina,  and  sometimes  white  spots  of  degeneration.  The 
papilla  is  often  much  swollen,  and  the  retinal  veins  distended 
and  tortuous,  while  the  arteries  are  small ;  but  these  appear- 
ances, as  well  as  the  number  of  the  hemorrhages,  vary  much  in 
diflerent  cases.  When  there  are  but  few  hemorrhages,  they  are 
situated  in  the  neighborhood  of  the  papilla  and  macula  lutea. 

365 


366  DISEASES   OF   THE   EYE. 

The  appearances  occasionally  resemble  those  of  albuminuric 
retinitis,  but  in  the  latter,  as  a  rule,  the  proportion  of  white 
spots  to  hemorrhages  is  greater  than  in  this  affection. 

Causes. — The  affection  is  found  most  commonly  in  connection 
vvith  cardiac  disease,  e.  g.,  valvular  insufficiency,  and  hypertro- 
phy of  the  left  ventricle;  or,  with  diseases  of  the  vascular  sys- 
tem, e.g.,  atheroma,  and  aneurisms  of  the  large  vessels.  Where 
it  is  due  to  disease  of  the  coats  of  the  arteries,  the  ophthalmo- 
scope will  occasionally  reveal  an  arterial  branch  altered  to  the 
appearance  of  a  white  thread ;  but,  usually,  the  degenerative 
change  does  not  interfere  with  the  transparency  of  the  vascular 
coats.  In  the  majority  of  cases  dependent  on  cardiac  or  vascular 
disease  the  retinal  affection  is  monocular.  This,  and  the  fre- 
quently sudden  onset  of  the  retinitis,  lead  Leber'*'  to  think  that 
some  second  factor  for  its  occurrence  exists,  probably  multiple 
embolisms  of  the  small  branches  of  the  central  artery.  Suppres- 
sion of  menstruation  or  other  wonted  discharge — such  as  that 
from  piles — has  been  observed  as  a  cause  of  hemorrhagic 
retinitis. 

A  peculiar  form  of  hemorrhagic  retinitis  is  sometimes  asso- 
ciated with  secondary  syphilis.  In  addition  to  the  usual  opacity 
of  the  retina  in  syphilitic  retinitis  (vide  infra),  a  portion  of  the 
retina  is  covered  with  numbers  of  small  round  hemorrhages 
lying  in  the  different  layers  of  the  retina,  while  a  connective 
tissue  development  is  occasionally  found  in  the  nerve-fibre 
layer,  in  the  form  of  white  stride  along  the  course  of  the  blood- 
vessels. 

The  disturbance  of  vision  is  considerable,  especially  if  the 
neighborhood  of  the  macula  lutea  be  much  involved. 

The  Prognosis  is  bad  in  severe  cases  of  hemorrhagic  retinitis. 
Relapses  are  common,  while  the  ultimate  tendency  is  toward 
atrophy  of  the  retina  and  papilla.  In  very  mild  cases  recovery 
may  come  about. 

The    Treatment  must   be    chiefly  expectant,   or  directed,  at 

*  Graefe  und  Sremisch's  Handhuch,  Bd.  v,  p.  570. 


THE    RETINA.  367 

most,  toward  procuring  rest  for  the  general  system,  or  for 
the  organ  primarily  at  fault.  Dry  cupping  on  the  temple, 
hot  foot-baths,  and  iodide  of  potassium  internally  may  be 
employed. 

Apoplexy  of  the  Retina. — This  differs  from  the  last-described 
disease  in  that  the  hemorrhages  are  found  in  a  retina 
free  from  other  diseased  appearances,  especially  from  ret- 
initis. 

With  the  Ophthalmoscope,  the  extravasations  of  blood  appear 
as  red,  or  almost  black,  spots  of  various  sizes  and  shapes.  Their 
number  and  position  in  the  fundus  are  also  variable.  They 
may  be  in  any  layer  of  the  retina,  and  may  sometimes  burst 
into  the  vitreous  humor,  and  sometimes  become  extravasated 
between  the  retina  and  choroid. 

Vision  is  interfered  with  according  to  the  position  and 
extent  of  the  hemorrhages.  Wherever  an  apoplexy  be  situated 
the  function  of  the  retina  at  that  place  is  suspended.  If  it  be 
at  the  macula  lutea,  central  vision  will  be  seriously  impaired  ; 
while  the  scotoma  produced  by  an  apoplexy  at  the  periphery  of 
the  fundus  may  pass  unnoticed  by  the  patient. 

Causes. — Retinal  apoplexies  are  most  common  in  advanced 
life,  with  atheroma  of  the  blood-vessels,  and  are  then  valuable 
as  a  warning  of  possibly  impending  cerebral  mischief  Other 
causes  are :  hypertrophy  of  the  left  ventricle ;  suppression 
or  irregularity  of  menstruation,  or  at  the  climacteric  period ; 
the  sudden  reduction  of  tension  of  the  eyeball  after  iridectomy 
for  glaucoma ;  the  gouty  diathesis  (Hutchinson) :  progressive 
pernicious  anaemia,  or  anaemia  from  loss  of  blood  (hsemateraesis, 
etc.),  or  from  exhausting  diseases.  In  connection  with  this 
latter  cause  of  retinal  apoplexy,  Stephen  Mackenzie  has  pointed 
out"^  that  when  the  corpuscular  richness  of  the  blood  falls 
below  50  per  cent.,  whatever  the  cause  of  the  anaemia,  the 
tendency  to  retinal  hemorrhage  is  present. 

In   young  people  of  both  sexes,  from  the  fourteenth  to  the 

"^  Trans.  Ophthal  Soc,  Dec.  13th,  1883. 


3(58  DISEASES   OF   THE    EYE. 

twentieth  year  of  age,  large  retinal  apoplexies,  which  may 
extravasate  into  the  vitreous  humor,  are  sometimes  seen,  and 
it  is  difficult  to  assign  a  cause  for  them.  Some  of  the  subjects 
are  weak  or  anaemic,  while  many  of  them  are  in  perfect  health. 
Neither  Eales*  nor  Niedent  have  found  these  apoplexies  in 
young  women,  but  this  does  not  conform  with  my  experience, 
nor  with  that  of  many  others. 

Prognosis. — The  apoplexies  are  observed,  in  the  course  of 
weeks  or  months,  to  become  paler  and  smaller,  often  leaving 
after  them  choroidal  changes,  or  grayish  spots  dependent  on 
degeneration  of  the  retina,  and  in  some  extreme  cases  atrophy 
of  the  whole  retina  may  result. 

Occasionally,  absorption  of  the  hemorrhages  is  accompanied 
by  complete  restoration  of  vision,  but  usually  the  scotomata 
remain.  Recurrences  of  the  hemorrhages  are  very  common. 
Glaucoma  comes  on  as  consecutive  to  retinal  apoplexies  in 
some  instances,  and  is  then  known  as  hemorrhagic  glaucoma, 
an  incurable  form  of  the  disease  (p.  307). 

In  other  cases  the  hemorrhage,  having  invaded  the  vitreous 
humor,  gives  rise  to  dense  permanent  opacity  in  it,  followed, 
perhaps,  by  detachment  of  the  retina. 

Treatment. — Active  measures  are  of  little  use.  Cold  com- 
presses at  first,  with  a  pressure  bandage,  and  dry  cupping  to  the 
temple,  may  be  employed.  The  general  state  of  the  patient 
must  be  attended  to,  and  no  violent  muscular  efforts  per- 
mitted. 

Retinitis  Albuminurica  occurs  as  a  complication  in  many 
cases  both  of  acute  and  chronic  nephritis,  and  in  the  albu- 
minuria of  pregnancy.  It  is  most  common  with  the  small 
granular  kidney,  but  may  attend  any  chronic  form  of  Bright's 
disease. 

The  Defect  of  Vinon  in  the  chronic  form,  although  often  an 
early  or  even  the  first  symptom,  is  never  associated  with  an  early 


*  Ophthal.  Review,  1882,  p.  41. 
tBerichtd.  Ophthal  Gesellsch.,  1882. 


THE    RETINA.  369 

stage  of  the  kidney  disease,  but  rather  with  a  late  stage  of  it,  and 
with  dilated  left  ventricle.  Both  eyes,  as  a  rule,*  are  affected, 
although  often  not  equally  so ;  vision  is  much  lowered,  and  even 
perception  of  light  may  be  wanting ;  but  the  blindness  is  not 
always  all  due  to  organic  changes  in  the  retina,  being  often 
largely  the  result  of  urcemia. 

Ophthalmoscopic  Appearances. — These  are  venous  hyperemia 
and  swelling  of  the  papilla,  and  of  the  retina  in  its  neighbor- 
hood ;  hemorrhages  on  the  papilla,  and  in  the  nerve-fibre  layer 
of  the  retina  ;  and  round  or  irregularly  shaped  white  spots  in  the 
retina,  arranged  in  a  zone  around  the  papilla,  some  three  papilla 
diameters  from  it.  These  changes  take  place  in  the  order  in 
which  I  have  enumerated  them.  The  hypertemia  and  engorge- 
ment of  the  veins,  often  very  great,  become  less  according  as  the 
white  spots  become  more  developed.  Xear  the  macula  lutea  no 
very  coarse  changes  usually  occur,  but  fine  white  dots  are  found, 
with  a  star-like  arranorement  converdno^  toward  the  macula. 
The  degree  in  which  all  these  different  changes  are  present 
varies  in  different  cases,  no  one  of  them  being  pathognomonic  of 
the  kidney  affection,  but  rather  the  grouping  of  the  whole 
picture  being  suggestive.  Sometimes  the  papillitis  is  so  intense 
as  to  simulate  that  formerly  know'n  as  "  congestion  papilla"  in 
cases  of  intracranial  tumor,  while  the  white  spots  are  sometimes 
developed  to  such  a  degree  as  to  become  confluent,  and  to  form 
one  large  white  plaque.  Again,  the  papillitis,  or  white  spots,  or 
both,  may  be  but  slightly  marked.  The  number  and  size  of  the 
hemorrhages  are  also  liable  to  great  variation.  Detachment  of 
the  retina  has  been  observed  in  a  few  cases,  and  in  some  the 
hemorrhages  burst  into  the  vitreous  humor. 

Some  of  the  white  spots  are  caused  by  fatty  degeneration  of 
the  outer  layers  of  the  retina  (the  retinal  vessels  passing  over 
them),  others  by  hypertrophy  of  the  nerve-fibre  layer  (the 
retinal  vessels  hidden  by  them).    The  fine  dots  about  the  macula 

*  A  few  cases  are  recorded  in  which  only  one  eye  was  attacked,  and  in 

several  of  these  it  was  found  that  but  one  kidney  was  present. 


370  DISEASES   OF   THE   EYE. 

lutea  are  the  result  of  fatty  degeneration   of  the  inner  ends  of 
Miiller's  fibres. 

The  connection  between  the  renal  and  retinal  affections  is  not 
known  with  certainty,  but  the  theory  that  the  latter  is  due  to 
chronic  uncmia  is  probably  correct. 

Prognosis. — In  these  cases  the  prognosis  as  regards  the 
patient's  life  is  bad  ;  but  if  the  general  disease  remain  sta- 
tionary, or  improve,  or  recover,  the  retinal  changes  may  im- 
prove or  disappear,  and  leave  the  retina  with  normal  appear- 
ances and  functions;  or  the  swelling,  hypersemia,  white 
spots,  and  hemorrhages  may  give  place  to  optic  atrophy, 
with  diminution  in  size  of  the  arteries,  pigmentary  alterations  in 
the  retina,  and  blindness. 

Treatment. — Dry  cupping  at  the  temple  is  about  the  only 
remedy  which  can  be  employed  directly  for  the  retinal  affection, 
and  I  will  not  say  that  it  is  of  much  use.  Taking  into  consider- 
ation the  serious  import  of  this  eye-symptom  for  the  life  of  the 
patient,  it  is  a  question  whether,  in  many  cases  of  pregnancy 
with  albuminuric  retinitis,  abortion  should  not  be  resorted  to, 
especially  if  the  pregnancy  have  still  some  months  to  run. 

Retinal  Affections  in  Diabetes. — There  is  no  one  condition  of 
the  retina  characterist*ic  of  diabetes,  although  undoubtedly 
retinal  affections  occasionally  do  complicate  it  in  an  advanced 
stage.  Small  retinal  hemorrhages  with  fine  changes,  in  the  form 
of  glistening  dots  about  the  macula  lutea,  somewhat  similar  to 
the  starlike  appearance  in  Bright's  disease,  form  perhaps  the 
most  common  and  suggestive  appearances.  In  other  cases  retinal 
hemorrhages  alone  are  found,  and  in  others  hemorrhagic  retini- 
tis ;  while  again,  the  so-called  typical  appearances  of  Bright's 
disease  may  be  presented.  There  are  often  opacities  of  hemor- 
rhagic origin  in  the  vitreous  humor,  and  iritis  may  come  on. 
Leber  lays  down  the  important  rule  that  in  all  cases  of  retinal 
hemorrhages  and  of  retinitis  hemorrhagica  the  urine  should  be 
examined  for  sugar. 

Retinitis  Leucaemica. — In  not  more  than  one-third  or  one 
fourth    (Leber)  of  the  cases   of  leucocythemia    does   a    retinal 


THE   RETINA.  371 

affection  occur,  and  it  is  not  always  of  the  same  type.  It  may 
consist  in  a  slight  diffuse  retinitis,  accompanied  by  some  extra- 
vasation of  pale  blood,  while  the  blood-vessels  are  also  pale,  the 
veins  being  much  distended,  and  the  arteries  small,  and  the 
choroid  of  an  orange-yellow  color.  Or,  it  may  resemble  a  case 
of  ordinary  hemorrhagic  retinitis. 

The  Appearances  most  characteristic  of  the  affection  are :  the 
papilla  pale,  with  indistinct  margins;  slight  opacity  of  the 
retina,  especially  along  the  vessels  ;  small  hemorrhages  ;  round, 
white,  elevated  spots,  up  to  2  mm.  in  diameter,  with  a  hemor- 
rhagic halo,  situated  by  preference  toward  the  periphery  of  the 
fundus  and  at  the  macula  lutea,  but  not  at  all,  or  only  in  very 
severe  cases,  in  the  zone  between  the  macula  and  the  equator  of 
the  eye.  These  white  spots  consist  of  extravasations  of  leuc?emic 
blood,  the  result,  Leber  thinks,  of  diapedesis. 

Vision  may  be  but  little  affected  if  the  macula  lutea  be  fairly 
free.  Hemorrhage  into  the  vitreous  humor  may  cause  complete 
blindness. 

Syphilitic  Retinitis  (or  Syphilitic  Choroido-Retinitis). — 
Inherited,  or  acquired,  constitutional  syphilis  is  liable  to  in- 
duce a  form  of  chronic  diffuse  retinitis.  In  the  acquired  disease 
it  is  a  later  secondary  symptom,  coming  on  between  the  sixth 
and  eighteenth  month,  often  only  in  one  eye. 

With  the  Ophthalmoscope  a  light  opacity  of  the  retina  is  seen 
extending  from  the  papilla  some  distance  into  the  retina,  and 
very  gradually  disappearing  toward  the  equator  of  the  eye. 
The  papilla  is  but  slightly  hypersemic,  while  its  margins  are 
indistinct,  like  those  of  the  moon  seen  through  a  light  cloud. 
The  artery  is  not  generally  altered,  and  the  vein  but  slightly 
distended.  Opacities  in  the  vitreous  humor  are  not  uncommon. 
They  may  be  membranous  or  thread-like,  but  a  diffuse  dust- 
like opacity,  filling  the  whole  vitreous  humor,  is  almost  pathog- 
nomonic of  a  syphilitic  taint,  and  may  create  much  difficulty  in 
the  ophthalmoscopic  diagnosis  of  the  retinal  affection. 

Disseminated  choroidal  changes,  in  the  form  of  small  yellowish 
spots  with   pigmentary   deposit,  are   very    frequent,  especially 


372  DISEASES   OF   THE   EYE. 

toward  the  equator  of  the  eye.  Many  observers,  indeed,  hold 
that  the  whole  process  is  primarily  in  the  choroid,  and  that 
the  retina  is  only  secondarily  affected.  Fine  whitish  dots 
and  pigmentary  changes  often  occur  about  the  macula  lutea. 

Vision  may  be  but  slightly  affected,  but  in  the  advanced 
stages  it  is  usually  much  lowered.  Central  or  peripheral 
scotoraata,  or  concentric  defects  of  the  field,  are  found.  The 
scotomata  are  often  positive,  i.  e.,  they  can  be  seen  by  the 
patient  as  dark  spots  in  the  field.  Night  blindness  is  a  constant 
symptom,  and  the  light-sense  is  enormously  diminished.  The 
patients  sometimes  complain  of  sparks  or  lights,  which  seem  to 
dance  before  their  eyes,  and  occasionally  also  of  a  diminution  in 
the  size  (micropsia)  of  objects,  or  of  a  distortion  (metaraorphop- 
sia)  of  their  outlines.  The  micropsia  is  believed  to  be  due  to  a 
separation  from  each  other  of  the  elements  of  the  layer  of  rods 
and  cones,  by  subretinal  exudation.  The  image  of  an  object 
then  comes  into  relation  with  fewer  of  these  elements,  and 
hence  the  mental  impression  is  that  of  a  smaller  object  than  is 
conveyed  by  the  image  formed  in  the  sound  eye,  or  on  a  sound 
part  of  the  same  retina. 

The  Progress  of  the  Disease  is  very  slow,  and  is  liable  to 
relapses.  In  the  late  stages  extensive  pigmentary  degeneration 
of  the  retina  may  come  on,  or  disseminated  choroiditis.  But  if 
the  cases  come  under  suitable  treatment  in  an  early  stage,  a  cure 
may  often  be  effected. 

Treatment. — The  only  remedy  which  is  of  real  value  is  mer- 
cury, and  that  in  an  early  stage.  It  should  be  used  in  a  pro- 
tracted course  of  some  weeks  by  inunction,  combined  at  discretion 
with  small  doses  of  calomel  internally.  Perchloride  of  mercury 
hypodermically,  in  -^  gr.  doses  once  a  day,  is  also  a  suitable 
measure.  If  mercurialization  be  effected, it  should  not  go  further 
than  a  very  slight  stomatitis.  Pilocarpine  hypodermically, 
Turkish  baths,  and  the  artificial  leech  at  the  temple  may  be  em- 
ployed as  adjuncts  to  the  treatment.  When  the  mercurial  course 
has  been  completed  iodide  of  potassium  should  be  prescribed  as 
an  after-treatment. 


THE   RETINA.  373 

Quinine  Amaurosis. — Quinine  in  large  doses,  and  very  occa- 
sionally in  small  doses,  is  liable,  in  some  individuals,  to  cause 
amblyopia,  which  may  amount  to  absolute  blindness,  accom- 
panied for  some  hours  or  days  by  great  deafness.  This  absolute 
blindness  is  never  more  than  temporary,  although  it  may  last 
for  some  weeks  ;  but  in  severe  cases  concentric  contraction  of  the 
field  is  apt  to  remain  permanently,  with  or  without  some  defect 
of  central  vision.  In  the  only  instance  of  this  more  serious  re- 
sult which  I  have  seen,  the  color  and  light-senses,  notwithstand- 
ing the  contracted  field  and  marked  seeming  optic  atrophy,  were 
normal ;  but  the  adaptation  of  the  retina,  as  shown  by  consider- 
able night-blindness,  was  defective. 

In  what  may  be  called  the  acute  stage  the  Ophthalmoscopic. 
Appearances  are  sometimes  normal,  but  pallor  of  the  optic  pa- 
pilla, with  scarcity  and  smallness  of  the  retinal  vessels,  is  the 
usual  condition.  Where  the  case  is  chronic — the  fields  remain- 
ing contracted,  although  central  vision  has  improved — the 
ophthalmoscope  may  discover  a  very  pale  optic  papilla  with 
minimal  vessels. 

The  retinal  ischemia  is  doubtless  the  immediate  Cause  of  the 
amblyopia,  and,  in  its  turn,  is  the  result  of  diminished  heart's 
action  and  lowered  arterial  tension,  both  of  which  have  been 
shown  to  be  produced  by  large  doses  of  quinine. 

Treatment. — Cessation  of  the  use  of  the  quinine.  Digitalis  in- 
ternally to  raise  the  arterial  tension,  nitro-glycerine  or  inhala- 
tions of  nitrite  of  amyl,  hypodermic  injections  of  strychnia,  and 
general  tonic  treatment  are  the  means  most  likely  to  promote  a 
cure. 

Retinitis  Pigmentosa  is  a  degenerative,  rather  than  an  inflam- 
matory, affection  of  the  retina.  It  is  extremely  chronic  in  its 
progress,  coming  on,  most  commonly,  in  childhood,  and  often 
resulting  in  complete,  or  almost  complete,  blindness  in  advanced 
life. 

Vision  is  much  affected,  but  the  symptom  most  complained  of 
is  night-blindness  (nyctalopia  =  vy$,  night;  wc'',  the  eye),  due 
rather  to  defective  power  of  retinal  adaptation  than  to  defective 


374  DISEASES   OF   THE    EYE. 

light-sense.  The  field  of  visiion,  moreover,  becomes  gradually 
contracted  until  only  a  very  small  central  portion  remains  ;  so 
that,  although  the  patient  may  still  be  able  to  read,  he  cannot 
find  his  way  alone — a  function  for  which  the  eccentric  parts  of 
the  field  are  the  most  important.  Finally,  the  last  remaining 
central  region  becomes  blind. 

The  Ophthalmoscopic  Appearances  consist  in  a  pigmentation  of 
the  nerve-fibre  layer  of  the  retina,  which  commences  in  the  peri- 
phery, and  in  the  course  of  years  advances  toward  the  macula 
lutea.  The  pigment  is  arranged  in  stellate  spots,  of  which  the 
processes  intercommunicate,  so  that  the  appearance  reminds  one 
of  a  drawing  of  the  Haversian  system  of  bone.  Pigment  is  also 
deposited  along  the  course  of  many  of  the  vessels,  hiding  them 
from  view.  The  degree  of  pigmentation  varies  much,  and  in 
some  cases  is  quite  absent,  and  the  diagnosis  then  has  to  depend 
upon  the  other  appearances  and  on  the  symptoms.  The  papilla 
is  of  a  grayish-yellow  color,  never  white,  and  the  vessels  are 
very  small. 

The  choroid  is  sometimes  slightly  affected,  irregularity  in  its 
pigmentation  being  observable. 

Pathology. — The  pigment  in  the  retina  is  believed  to  wander 
into  it  from  the  pigment  epithelium  layer.  The  other  patho- 
logical changes  in  the  retina  consist  in  hyperplasia  of  its  con- 
nective-tissue elements,  and  thickening  of  the  walls  of  the  vessels 
at  the  expense  of  their  lumen. 

The  choroidal  vessels,  too,  are  altered,*  owing  to  an  endar- 
teritis, which  causes  hypertrophy  of  their  coats,  with  more  or 
less  obliteration  of  their  lumen.  In  fact,  it  seems  probable  that 
the  primary  seat  of  the  diseased  process  is  in  the  choroid  ;  and 
that  it  is  the  changes  in  it  which  cause  the  pigment  from  the 
pigment-epithelium  layer  to  wander  into  the  retina. 

Causes. — Retinitis  pigmentosa  often  affects  more  than  one 
member  of  a  family,  the  patients  being  frequently  defective  in 
intelligence,  or  deaf  and  dumb.   Many  of  them  are  the  offspring 


*  Wagenraann,  A.  v.  Graefe's  Archiv,  xxxvii,  1,  p.  2:J0. 


THE    RETINA.  375 

of  marriages  of  consanguinity,  and  in  others  an  inherited  syphi- 
litic taint  is  present,  while  in  others  no  cause  can  be  assigned. 

Treatment  is  of  little  use.  At  best,  one  may  stimulate  the 
torpid  retina  by  hypodermic  injections  of  strychnia  or  with  the 
continuous  current.  The  latter  means  has  found  an  advocate  in 
Dr.  Gunn,*  and  I  have  seen  several  cases  in  which  temporary 
benefit  was  obtained  from  it. 

Retinitis  Punctata  Albescens  (Mooren) ;  Retinitis  Centralis 
Punctata  at  Striata  (Hirschberg). — A  few  cases  of  this  peculiar 
aflTection  have  been  described.f  These  have  occurred  in  middle- 
^ged  or  elderly  people  whose  general  health  was  good,  or,  if  dis- 
ordered, was  not  similarly  so  in  any  two  cases.  The  defect  of 
vision  may  come  on  rapidly,  or  may  be  gradually  developed  in 
the  course  of  many  years.  It  consists  in  a  lowering  of  the  cen- 
tral vision,  with  positive  or  relative  scotoma,  or  both  may  be 
present ;  but  the  eccentric  field  remains  intact. 

The  Ojyhthalvioscope  discovers  great  numbers  of  minute,  white, 
glistening  dots  and  fine,  white  striae  in  the  retina,  chiefly  between 
the  papilla  and  macula.  A  retinal  hemorrhage  was  noted  in 
one  case,  and  in  only  one  was  slight  papillitis  present.  The 
aflTection  is  probably  of  inflammatory  origin. 

Treatment  consisted  in  Heurteloup's  leech,  iodide  of  potassium, 
protection  of  the  eyes,  and  care  of  the  general  health.  Cure 
took  place  in  one  case,  while  in  no  instance  did  serious  blindness 
come  on. 

Development  of  Connective  Tissue  in  the  Retina,  or  Retinitis 
Proliferans. — Extensive  white  striae,  formed  of  connective  tissue, 
are  sometimes  seen  in  the  retina,  and  may  even  conceal  the  ves- 
sels and  papilla.  They  are  the  result  of  hemorrhages  according 
to  Leber,  and  of  an  inflammatory  process  according  to  Manz. 
Hemorrhages  in  the  retina  or  in  the  vitreous  humor,  or  in  both, 
are  generally  present  at  some  period  (p.  366).     Vision  is  often 

*  Ophthal.  Hosp.  Rep.,  vol.  x,  p.  161. 

t  Mooren,  "Funf  Lustren  Ophthalmologischer  Wirksamkeit,"  p.  216. 
Hirschberg,  Centralblatt  f.  prak.  Augenheilkunde,  1882,  p.  330. 


376  DISEASES   OF   THE   EYE. 

but  slightly  affected,  but  the  danger  of  recurrent  intraocular 
hemorrhages  renders  the  ultimate  prognosis  bad,  as  a  rule. 

Treatment. — Heurteloup's  leech.  Iodide  of  potassium  or  per- 
chloride  of  mercury.     Protection  spectacles. 

Detachment  of  the  Retina. — This  condition  consists  in  a  sepa- 
ration of  the  retina  from  the  choroid,  the  intervening  space  being 
occupied  by  a  clear,  serous  fluid.  It  is  not  usual  to  employ  the 
term  when  it  is  a  solid  neoplasm  only  that  lies  between  retina 
and  choroid. 

If  the  media  be  clear,  and  the  detached  portion  extensive,  the 
diagnosis  is  not  difficult. 

The  OpJithalmoscojye  shows  a  grayish  reflex  from  a  position  in 
front  of  the  fundus  oculi,  and  to  the  surface  from  which  the  re- 
flex is  obtained  a  wave-like  motion  is  imparted  -svhen  the  eyeball 
is  moved.  Over  this  grayish  surface  the  retinal  vessels  run,  and 
they  serve  to  distinguish  a  detached  retina  from  any  other  dis- 
eased condition  with  a  somewhat  similar  appearance.  They  seem 
black,  not  red,  in  consequence  of  absorption  of  the  transmitted 
light,  and  are  hidden  from  view  here  and  there,  in  the  folds  of 
the  detached  retina.  In  many  cases  a  rent  in  the  detached  retina, 
through  which  the  choroid  can  be  discerned,  will  be  discovered. 

The  detachment  may  commence  in  any  portion  of  the  fundus, 
but  most  commonly  above  ;  yet,  owing  to  gravitation  of  the 
fluid,  it  ultimately  settles  in  the  lower  half  of  the  fundus,  and 
hence  this  is  the  most  common  place  to  find  it,  the  part  first  de- 
tached having  become  replaced.  The  diagnosis  is  more  difficult 
if  there  be  but  little  fluid  behind  the  retina,  or  if  there  be  opaci- 
ties in  the  vitreous  humor. 

Vinon  is  affected  according  to  the  position  and  extent  of  the 
detachment.  Central  vision  may  be  quite  normal  if  the  macula 
lutea  and  its  immediate  neighborhood  are  intact.  The  patients 
complain  of  seeing  objects  distorted,  of  a  black  veil  which  seems 
to  hang  over  the  sight,  and  sometimes  of  black,  floating  spots  be- 
fore the  eye,  due  to  opacities  in  the  vitreous  humor.  These 
symptoms  often  come  on  suddenly  in  an  eye  which  has  hitherto 
had  good  sight. 


THE   RETINA.  377 

The  field  of  vision,  ou  examination,  will  show  a  defect  corres- 
ponding to  the  position  of  the  detachment.  If,  for  example,  it 
be  below,  the  defect  will  be  in  the  upper  part  of  the  field.  If 
the  detachment  be  fresh,  the  retina  not  having  yet  undergone 
secondary  changes,  and  if  the  quantity  of  subretinal  fluid  be  not 
great,  the  defect  may  only  amount  to  an  indistinctness  of  vision  ; 
but,  later  on,  when  infiltration  and  connective  tissue  degenera- 
tion of  the  detached  part  come  about,  fingers  may  not  be  counted 
at  the  same  place.  The  phosphenes"^  of  the  detached  portion 
are  wanting. 

Should  the  detachment  become  complete,  little  more  than 
power  of  perception  of  light  may  be  present.  Total  detachment 
is  followed  by  cataract,  and  often  by  iritis  and  phthisis  bulbi. 
The  detachment  may  remain  stationary,  and  not  extend  to  the 
whole  fundus,  or  the  retina  may  return  to  its  normal  position. 
Such  a  happy  result,  however,  is  most  rare. 

Causes. — Myopic  eyes — which  we  know  are  so  frequently 
affected  with  choroiditis  and  disease  of  the  vitreous  humor — are 
those  most  subject  to  detachment  of  the  retina,  but  idiopathic 
detachment  occurs  also  in  eyes  which  are  apparently  healthy. 
Blows  upon  the  eye  may  produce  detachment,  the  retro-retinal 
fluid  being  serous  or  bloody.  Some  punctured  wounds  of  the 
sclerotic,  also,  in  the  course  of  healing,  by  dragging  on  the 
retina,  give  rise  to  it.  Choroidal  tumors,  especially  those  situ- 
ated in  the  posterior  segment  of  the  fundus,  usually  cause  de- 
tachment in  an  early  stage  of  their  growth,  and  the  complication 
renders  their  diagnosis  more  difficult  (p.  257). 

*  Phosphene  is  the  subjective  sensation  of  light  experienced  when  the 
eyeball  is  pressed  upon.  For  clinical  purposes  it  is  best  tested  by  gentle 
pressure  with  a  blunt  point  (head  of  a  bodkin,  or  large  sized  probe) 
applied  to  the  eyeball  through  the  eyelid.  The  phosphene  of  any  region 
is  tested  by  applying  pressure  to  that  part  of  the  globe  ;  thus,  if  in  a 
healthy  eye  the  individual  look  down,  and  pressure  be  applied  to  the 
upper  part  of  the  globe  through  the  eyelid,  the  phosphene  will  be  seen 
appearing  below,  but  if  there  be  a  detachment  of  the  retina  at  the  place 
pressed  on  no  phosphene  is  seen. 
32 


378  DISEASES   OF   THE   EYE. 

Leber*  observed  that  in  non-traumatic  detachment  a  perfora- 
tion or  rent  in  the  detached  portion  is  very  frequently  to  be 
seen  with  the  ophthalmoscope,  and  holds  that  it  is  probably  al- 
ways present,  although  sometimes,  from  being  hidden  behind  a 
fold  of  the  retina,  it  cannot  be  found.  He  was  led  from  this,  and 
from  his  pathological  investigations  and  experiments  upon  ani- 
mals, to  think  that  the  detachment  was  due  to  shrinking  of  a 
diseased  vitreous,  which  first  became  slightly  separated  from  the 
retina,  and  that  then — at  some  place  where  the  retina  and  hya- 
loid had  become  adherent  from  the  inflammatory  process — a  rent 
was  produced  in  the  retina  by  the  shrinking  process  in  the  vitre- 
ous. And  he  concluded  that  through  this  rent  the  fluid,  which 
is  always  present  behind  the  vitreous  in  cases  of  detachment  of 
that  body,  makes  its  way  behind  the  retina  and  separates  the 
latter  from  the  choroid.  All  this  has  been  fully  borne  out  by 
Nordenson's  pathological  researches,'}"  who  has  ascertained, 
moreover,  that  disease  of  the  ciliary  body  and  choroid  is  the 
primary  cause,  although  we  may  not  be  always  able  to  detect  it 
with  the  ophthalmoscope,  and  that  the  pathological  change  in 
the  vitreous  humor  consists  in  an  alteration  in  its  connective 
tissue  elements,  resulting  in  the  deleterious  shrinking. 

Treatment. — Evacuation  of  the  subretinal  fluid  by  puncture  of 
the  sclerotic  was  first  proposed  by  Sichel,  and  has  been  culti- 
vated by  de  Wecker.  He  uses  an  instrument  like  a  broad  needle, 
with  a  sharp  point  and  two  blunt  edges,  which  is  entered  through 
the  sclerotic  and  choroid  at  a  place  corresponding  to  the  position 
of  the  detachment,  but  not  so  deeply  as  to  reach  the  retina,  lest 
thereby  it  be  further  displaced.  The  instrument  is  then  given  a 
quarter  of  a  rotation,  to  make  the  wound  gape,  so  as  to  admit  of 
the  flowing  off"  of  the  fluid.  If  possible,  a  position  near  the 
equator  of  the  globe  and  between  two  recti  muscles  should  be 
selected  for  the  operation.  Moreover,  the  incision  should  lie 
parallel  to  the  direction  of  the  orbital  muscles,  so  that  the  cho- 

*Berichtd.  Ophthal.  Gesellsch.,  1882,  p.  18. 
t  "Die  Netzhautablosung  "  (Wiesbaden,  1887). 


THE   RETINA.  379 

roidal  vessels  may  be  injured  as  little  as  possible.  A  firm  band- 
age is  applied,  and  the  patient  kept  in  bed  for  eight  or  ten 
days. 

The  dorsal  position  in  bed,  with  a  pressure  bandage  on  the 
eye,  maintained  for  from  four  to  six  weeks,  has  produced  reposi- 
tion of  the  detachment  in  some  cases.  The  method,  if  properly 
carried  out,  is  most  trying  to  the  patient. 

The  few  cures  which  have  been  reported  as  accomplished  by 
these  means  probably  depended  upon  the  retina  again  coming  in 
contact  with  the  choroid,  and,  owing  to  some  slight  inflammatory 
process,  adhering  to  it.  For  the  most  part  the  cure  is  only  tem- 
porary, and  in  such  cases  we  may  suppose  that  no  adhesion 
sprang  up,  but  that  the  temporary  cure  was  due  to  a  return  of 
the  subretinal  fluid,  through  the  hole  in  the  retina,  to  its  original 
position  between  the  retina  and  vitreous.  Soon,  however,  it 
makes  its  way  back  again  through  the  hole,  and  the  detachment 
recurs. 

Schoeler*  injects  tincture  of  iodine  into  the  vitreous  humor 
in  front  of  the  detached  retina,  in  order  to  press  it  back  to  the 
choroid  and  to  produce  a  plastic  choroido-retinitis,  which  may 
unite  the  two  coats.  He  has  reported  several  good  results  by 
this  method,  but  some  who  have  tried  it  have  experienced  vio- 
lent inflammatory  reaction  in  the  eyes  operated  on,  with  dis- 
astrous consequences. 

Grossmannf  tried  aspiration  of  the  subretinal  fluid,  with 
simultaneous  increase  of  the  pressure  in  the  vitreous  humor,  by 
injections  into  the  latter  of  four  or  five  drops  of  an  indifferent 
fluid,  namely,  a  0.75  per  cent,  lukewarm  solution  of  common 
salt.  The  results  obtained  were  encouraging  in  the  three  cases 
treated,  but  I  am  not  aware  of  any  further  reports. 

Galezowski  j  simply  aspirates  the  subretinal  fluid. 

*  "  Zur  operativen  Behandlung  und  Heilung  der  Netzhautablosung  " 
(Berlin,  1889). 
t  Ophthalmic  Review,  1883,  p.  89. 
X  Recueil  d^  Ophthalmologic,  Mars,  1888. 


380  DISEASES   OF   THE   EYE. 

Pilocarpine,  used  hypodermically,  has  been  praised  by  some 
as  a  mode  of  treatment,  as,  also,  salicylate  of  sodium  internally. 

Formerly  an  active  mercurial  treatment  used  to  be  employed, 
with  the  object  of  obtaining  absorption  of  the  fluid. 

The  Prognosis  of  every  case  of  detached  retina  is  bad,  spon- 
taneous cure  being  extremely  rare,  and  the  treatment  of  the  dis- 
ease remaining  one  of  the  weakest  points  of  ophthalmic  thera- 
peutics. Moreover,  both  eyes  are  often  affected,  one  after  the 
other.  The  cures  by  any  one,  or  by  any  combination  of  the 
above  methods  of  treatment,  are  few  and  far  between  ;  and  when, 
sometimes,  the  retina  does  return  to  its  place,  there  is  still  the 
danger  of  a  recurrence  of  the  detachment.  The  most  favorable 
cases  are  those  due  to  choroiditis ;  the  most  unfavorable  those 
due  to  posterior  staphyloma. 

Cysticercus  under  the  Retina. — The  cysticercus  of  the  taenia 
solium  in  the  eye  is  extremely  rare  in  these  countries,  but  not  so 
in  Germany.  Its  most  frequent  seat  is  between  the  retina  and 
choroid,  where  it  is  recognized  with  the  ophthalmoscope  as  a 
sharply  defined,  bluish-white  body  with  bright  orange  margin. 
At  one  point  of  the  cyst  there  is  a  very  bright  spot,  which  cor- 
responds with  the  head  of  the  entozoon.  Wavelike  motions 
along  the  contour  of  the  cyst  should  be  looked  for,  to  confirm 
the  diagnosis.  The  cysticercus  may  move  from  its  original 
position,  and,  in  so  doing,  cause  considerable  detachment  of  the 
retina.  Delicate,  veil-like  opacities  are  apt  to  form  in  the 
vitreous  humor,  and  are  almost  characteristic  of  the  presence  of 
cysticercus. 

The  entozoon  may  become  encapsuled  behind  the  retina,  or  it 
may  burst  into  the  vitreous  humor  (p.  362)  ;  and,  finally,  chronic 
iridocyclitis,  with  total  loss  of  sight  and  phthisis  bulbi,  is  apt  to 
come  on. 

Treabnent. — We  are  not  acquainted  with  any  anthelmintic 
which  will  act  upon  the  entozoon  in  the  eye.  Removal  of  the 
cyst  by  operation  is  the  only  means  by  which  the  eye  can  be 
saved,  and  this  measure  can  only  be  resorted  to  when  the 
position   of  the   cysticercus   admits  of   it.      By  a  well-placed 


THE    RETINA.  381 

puncture  through  the  sclerotic  and  choroid  the  entozoon  may 
then  be  evacuated. 

Aneurism  of  the  Central  Artery  of  the  Retina. — Only  two 
cases  *  of  this  are  recorded  as  having  been  observed  during  life, 
ajid  these  were  in  men  aged  respectively  twenty  and  forty.  In 
one  of  these  cases  there  were  also  extensive  connective  tissue 
changes  in  the  retina,  the  veins  were  dilated  in  places,  and  only 
one  eye  was  affected.  The  minute  aneurismal  dilatations  were 
globular  and  situated  laterally  on  the  vessels,  or  they  were  fusi- 
form and  involved  the  whole  of  its  lumen.  The  number  of 
aneurisms  in  an  eye  varied  from  three  to  nine.  Neither  case 
was  followed  to  its  end ;  but  it  is  to  be  presumed  that  such  eyes 
would  run  great  risk  of  being  ultimately  lost  through  intra- 
ocular hemorrhage. 

A  rational  Treatment  for  the  condition  can  hardly  be  devised. 

Embolism  of  the  Central  Artery  of  the  Retina. — Sudden  or 
very  rapid  blindness,  beginning  at  the  periphery  of  the  field  and 
advancing  toward  the  centre,  is  the  only  symptom  experienced 
by  the  patient. 

Immediately  after  the  attack  the  Ophthalmoscope  shows  a 
marked  pallor  of  the  papilla,  while  the  artery  and  its  branches 
are  empty  of  blood,  resembling  fine  white  threads,  and  the  veins 
are  diminished  in  size  at  the  papilla,  but  increase  somewhat 
toward  the  periphery.  Pressure  on  the  eyeball  produces  no 
pulsation  nor  change  in  calibre  of  the  vessels,  as  it  does  in  a 
sound  eye.  Usually  on  the  following  day  the  central  region  of 
the  retina  begins  to  assume  a  grayish-white,  opaque  appearance, 
consequent  on  disturbance  of  nutrition,  in  the  midst  of  which 
the  macula  lutea  is  seen  as  a  purple-red  spot.  The  little  blood 
contained  in  the  vessels  may  soon  be  seen  divided  into  short 
columns  with  colorless  interspaces,  and  these  move  along  the 
vessels  with  a  slow,  jerky  motion.  Minute  hemorrhages  often 
occur,  most  commonly  between  the  macula  and  the  papilla. 

*  Story  and  Benson,  Trans.  Ophthal.  Sac,  1883,  p.  108 ;  and  Perinow, 
CentralhLf.  AugenheilTcunde,  1883,  p.  392. 


382  DISEASES   OF   THE   EYE. 

The  peculiar  appearance  of  the  macula  lutea  is  certainly  not 
due  to  hemorrhage.  According  to  Liebreich  it  is  merely  a  con- 
trast effect,  the  red  color  of  the  choroid  shining  through  where 
no  nerve-fibre  layer  is  present.  Leber  suggests  that  the  color 
may  be  due  to  the  retinal  purple. 

The  infiltration  of  the  retina  passes  away  in  a  few  weeks,  and 
also  the  peculiar  appearance  of  the  macula  lutea,  while  atrophy 
of  the  retina  and  papilla  usually  supervene. 

Embolism  of  a  branch  only  of  the  central  artery  has  been 
observed.  In  these  cases  the  infiltration  and  the  defect  of 
vision  are  confined  to  the  part  of  the  retina  supplied  by  the 
embolized  branch. 

Prognosis. — Vision  may  improve  for  a  time,  but  when  atrophy 
commences  it  falls  back  again,  and,  finally,  power  of  perception 
of  light  is  lost.  Cases  of  embolism  of  a  branch  are  more  likely 
to  recover. 

Causes. — Endocarditis ;  mitral  disease  ;  atheroma  of  the  large 
arteries  of  the  body;  aneurism  of  the  aorta;  pregnancy;  Bright's 
disease.  Two  cases  of  chorea  with  embolism  of  the  central 
artery  are  recorded.*  But  it  is  said  also  to  occur  in  healthy 
persons  without  any  discoverable  cause. 

Treatment. — Repeated  paracentesis  of  the  anterior  chamber 
has  been  tried,  and  also  iridectomy,  with  the  object  of  reducing 
the  tension,  and  in  this  way  promoting  a  collateral  flow  of  blood, 
by  means  of  the  only  ascertained  (Leber)  communications 
betw^een  the  retinal  and  choroidal  vascular  systems;  namely, 
at  the  entrance  of  the  optic  nerve.f  These  attempts  have  been 
unsuccessful. 

*  H.  R.  Swanzy,  R.  L.  0.  H.  Reports,  September,  1875 ;  and  A. 
Benson,  Ophihal.  Review,  January,  1886. 

t  Gowers  ("  Manual  of  Medical  Ophthalmoscopy,"  p.  31)  is  of  opinion 
that  there  are  other  anastomoses  between  these  systems,  probably  by 
connection  with  the  long  ciliary  arteries.  A  cilio-retinal  vessel  passing 
from  the  choroid  or  sclerotic  at  the  papilla  to  the  region  of  the  macula 
lutea  is  not  an  uncommon  vascular  anomaly  ;  and  Benson  has  published 
a  case  of  embolism  [Ophihal.  Hasp.  Rep.,  vol.  x,  p.  336)  in  which  the 


THE   RETINA.  383 

Several  cases  have  been  published,  in  which  the  circulation, 
which  probably  was  not  completely  impeded  by  the  embolus, 
was  restored  and  good  vision  regained,  the  recovery  being 
probably  due  to  the  manipulations  of  the  eyeball  made  in 
each  case  for  the  purpose  of  observing  the  effect  of  pressure 
on  the  vessels.  So  long  as  the  pressure  was  maintained,  a 
column  of  blood  was  being  stored  up  behind  the  embolus,  and, 
on  removal  of  the  pressure,  rushed  forward  against  the  impedi- 
ment, carrying  it  into  some  more  remote  vessel  or  into  the 
general  vascular  system.  In  fresh  cases,  massage  of  the 
eyeball  suitably  applied  would  therefore  always  be  worth  the 
trial. 

Thrombosis  of  the  Retinal  Artery. — Blocking  of  the  artery 
may  occur  spontaneously,  from  thrombosis  due  to  failure  of  the 
heart's  action  and  slowing  of  the  arterial  flow,  the  result,  in  its 
turn,  of  cardiac  disease,  spasm  of  the  blood-vessels,  disease  of  the 
walls  of  the  vessels,  or  alterations  in  the  quantity  and  amount 
of  blood. 

The  Ophthalmoscopic  Signs  are  in  all  respects  similar  to  those 
of  embolism. 

The  Diagnosis  between  thrombosis  and  embolism  of  the 
central  artery  can  only  be  made  by  certain  symptoms  which 
precede  or  accompany  the  attack  in  thrombosis,  but  are  want- 
ing in  embolism.  These  are :  previous  attacks  of  transient 
blindness  in  the  blind  eye,  a  simultaneous  attack  of  blindness 
in  the  fellow  eye,  and  faintness,  giddiness,  and  headache  at  the 
onset  of  the  blindness. 

Treatment. — When  transient  attacks  of  blindness  are  com- 
plained of,  it  is  important  to  overhaul  the  patient's  general 
state,  and  to  correct,  so  far  as  possible,  any  condition  which 
might  be  the  cause  of  feeble  circulation.  When  the  true 
attack  comes  on,  manipulation  of  the  eyeball  applied  immedi- 


presence  of  such  an  artery  seemed  to  have  a  favorable  influence  for 
the  progress  of  the  case,  good  central  vision  being  recovered,  although 
the  field  remained  concentrically  contracted. 


384  DISEASES   OF   THE   EYE. 

ately,  or  paracentesis  of  the  anterior  chamber,  might  prove  of 
use. 

Glioma  of  the  Retina. — This  is  a  malignant  growth,  which  is 
found  almost  exclusively  in  young  children,*  and  may  even  be 
congenital.  Owing  to  the  age  of  the  patients,  the  incipient 
stages  of  the  disease  are  seldom  observed,  for  they  are  un- 
attended by  pain  or  inflammation. 

The  growth  commences  as  small,  white,  disseminated  swellings 
in  the  retina,  usually  in  one  or  other  of  the  granular  layers, 
more  rarely  in  the  nerve-fibre  layer.  The  retina  is  apt  to  be- 
come detached  at  an  early  period,  but  there  are  exceptions  to 
this,  especially  when  the  disease  starts  from  the  nerve-fibre  layer. 
In  the  early  stages  there  is  no  iritis,  cyclitis,  or  opacity  of  the 
vitreous  humor,  and  the  iris  periphery  is  not  retracted — points 
which  especially  enable  us  to  distinguish  it  from  pseudo-glioma 
(vide  Purulent  Inflammation  of  the  Vitreous  Humor,  Chap. 
XIV,  p.  367).  Secondary  glaucoma  finally  comes  on.  The 
optic  nerve  may  become  involved  at  an  early  period  ;  but,  sooner 
or  later,  it  invariably  does  so,  leading  then  to  glioma  of  the 
brain.  When  the  tumor  has  filled  the  eyeball  it  bursts  out- 
ward, usually  at  the  corneo-sclerotic  margin,  and  then  grows 
more  rapidly,  and  often  to  an  immense  size,  as  a  fungus  h?ema- 
todes.  The  orbital  tissues  become  involved,  and  even  the  bony 
walls  of  the  orbit,  while  secondary  growths  in  other  organs,  more 
especially  in  the  liver,  are  not  rare. 

The  diagnosis  between  glioma  of  the  retina  and  tubercle  of  the 
choroid  (p.  258),  when  the  latter  occurs  in  young  children,  is 
sometimes  diflficult  or  impossible,  but,  in  view  of  treatment,  not 
of  great  importance,  as  in  either  case  the  eye  must  be  enu- 
cleated. 

Treatment. — The  only  hope  of  saving  the  patient's  life  lies  in 
enucleation  at  an  early  stage  or  before  the  optic  nerve  becomes 
diseased.     It  is  important,  in  removing  the  eyeball,  to  divide  the 

*  A  case  of  Glioma  Retinae  in  a  man  aged  twenty-one  is  reported  by 
Mervill,  in  the  Trans.  American  Ophihal.  Soc,  vol.  iii,  p.  364. 


THE   RETINA.  385 

nerve  as  far  back  as  possible,  and  if  the  orbital  tissues  be  al- 
ready diseased  to  remove  all  suspicious  portions  of  thera. 

Blinding  of  the  Retina  by  Direct  Sunlight.— This  is  especially 
likely  to  occur  on  the  occasion  of  solar  eclipses  by  observation 
with  unprotected  eye. 

Immediately  after  the  exposure,  the  patients  complain  of  a 
dark  or  semi-blind  spot  in  the  centre  of  the  field  of  vision ;  a 
positive  scotoma,  in  short,  which  may  even  be  absolute,  and 
which  interferes  with  vision  in  proportion  to  the  length  of  the 
exposure.     Objects  may  also  seem  twisted  or  otherwise  distorted. 

The  Ojihthalmoscojye  shows  a  small,  bright,  white  spot  at  the 
fovea  centralis,  surrounded  by  a  blood-red  ring,  which  shades 
off  into  the  normal  color.  When  the  cases  are  not  severe  im- 
provement in  vision  takes  place,  but  complete  recovery  is  not 
common. 

Czerny,  and  also  Deutschmann,'^  demonstrated  that  concentra- 
tion of  the  direct  rays  of  the  sun  on  the  rabbit's  retina  gives  rise 
to  coagulation  of  the  retinal  albumin,  with  vascular  reaction,  dia- 
pedesis  of  blood  corpuscles,  and  pigmentary  disturbances ;  and 
it  is  probable  that  the  changes  in  the  human  retina  produced  by 
exposure  to  direct  sunlight  are  of  similar  nature. 

This  accident  is  not  analogous  to  snow-blindness  (Chap. 
XVII). 

Treatment — Hypodermic  injections  of  strychnia,  the  constant 
galvanic  current,  and  dry  cupping  on  the  temple  afford  the  best 
chances  for  promoting  the  cure.  Dark  protection  spectacles 
should  be  worn. 

Neurasthenic  Asthenopia,  or  Retinal  Anaesthesia. — This  pecu- 
liar and  rather  rare  affection  is  one  about  which  we  have  still 
much  to  learn.  It  is  a  complex  of  eye-symptoms  in  connection 
with  a  debilitated  state  of  the  general  nervous  system,  the  eye 
itself  being  organically  healthy.  These  Symptoms  are — 1.  Di- 
minished, but  fluctuating,  acuteness  of  vision.  The  effort  or 
desire  to  see  well  is  often  the  signal  for  the  acuteness  of  vision  to 

*  J.  V.  Graefes  Arcliiv,  Bd.  xxviii,  Abt.  3,  p.  241. 


386  DISEASES   OF   THE   EYE. 

fail.  2.  The  rapid  disappearance  of  objects  from  view,  if  looked 
at  too  long.  3.  Attacks  of  defective  sight,  with  positive  scoto- 
mata  coming  on  suddenly  and  without  provocation,  and  lasting 
for  a  few  minutes.  4.  Apparent  contraction  of  the  field  of 
vision.  If  a  perimetrical  examination  be  made  the  field  will  be 
found  contracted  ;  but,  as  Wilbrand"^  has  pointed  out,  this  con- 
traction is  merely  a  sign  of  retinal  exhaustion,  as  indicated  by 
the  fact  that  the  longer  the  examination  is  continued  the  more 
contracted  does  the  field  become.  5.  Optical  impressions  are 
retained  but  a  short  time.  The  appearance  of  persons,  places, 
etc.,  is  not  remembered  when  seen  soon  again.  6.  Muscular 
asthenopia.  Insufficiency  of  the  internal  recti  is  often  present, 
as  well  as  defective  accommodation.  7.  Hypersesthesia  of  the 
retina.  Dazzling  is  caused  by  even  moderate  light,  and  strong 
contrasts  of  light  and  shade  are  distressing,  while  the  acuteness 
of  vision  is  often  improved  when  blue  or  smoked  glasses  are 
worn. 

The  Ophthalmoscopic  Appearaoices  are  normal,  or  consist  merely 
of  some  hypersemia  of  the  optic  papilla. 

The  general  symptoms  of  the  condition  consist  in  insomnia ; 
tinnitus;  subjective  sensations  of  hearing;  exalted,  or,  again, 
defective  sensations  of  taste  and  smell ;  sensations  referred  to 
the  skin,  such  as  formication,  itching,  burning,  numbness,  heat, 
and  cold  ;  great  restlessness  of  body  ;  depression  of  spirits  ;  want 
of  mental  energy  ;  absent-mindedness  ;  weariness. 

The  persons  in  whom  the  affection  is  most  common  are 
children  before  and  at  the  time  of  puberty,  and  women  labor- 
ing under  hysteria,  anaemia,  chlorosis,  ovarian  irritation,  or 
displacement  of  the  uterus;  but  it  is  also  occasionally  found  in 
men. 

Treatment. — Any  uterine  or  other  local  disorder  must  be 
relieved,  so  far  as  possible.  Rest  of  body  and  mind  is  to  be 
enjoined,  with  fresh  air  and  moderate  exercise.  Strychnine, 
hypodermically,  is  a  valuable  remedy  in  the  affection,  and  with 

*  Archives  of  Ophthalmology^  xii,  428. 


THE    RETINA.  387 

it  iron  and  quinine,  internally,  may  be  associated,  and  bromide 
of  potassium  with  hyoscyamus  to  promote  sleep.  In  some, 
especially  in  hysterical  cases,  valerianate  of  zinc  is  beneficial. 
Sea-bathing  and  cold  shower-baths,  with  change  of  air,  are 
valuable  adjuncts  of  the  treatment.  Blue  or  smoked  protection 
glasses  are  most  grateful  to  the  patient  and  promote  the  cure, 
but  the  spectacle-frames  often  cause  annoyance  by  their  pres- 
sure on  the  nose  or  face.  Errors  in  refraction  should  be 
corrected. 

The  Prognosis  is  favorable,  inasmuch  as  ultimate  recovery  is 
assured,  but  the  course  of  the  affection  is  excessively  chronic, 
extending  over  months  or  years,  with  frequent  relapses. 

Traumatic  Anaesthesia  of  the  Retina. — A  blow  on  the  eye 
from  a  fist,  cork  from  a  bottle,  etc.,  is  liable  to  produce  con- 
siderable amblyopia,  with  concentric  contraction  of  the  field, 
which  may  continue  for  a  long  time,  while  the  Ophthalmoscopic 
Appearances  are  normal.  Ultimately,  these  cases  usually  re- 
cover, an  event  which  may  be  decidedly  promoted  by  the  use  of 
strychnine  hypodermically,  but  very  defective  sight  sometimes 
remains  permanently. 

Commotio  Retinae,  or  Traumatic  (Edema  of  the  Retina,  is  the 
result  of  a  blow  upon  the  eye.  Within  a  few  hours  after  the 
accident  the  Ophthalmoscope  reveals  a  white  cloudiness  of  a 
portion  of  the  retina,  usually  in  the  neighborhood  of  the  optic 
papilla  and  macula,  but  sometimes  more  eccentrically,  and 
sometimes  there  are  two  opaque  patches.  The  opacity  increases 
in  intensity  and  spreads  somewhat.  The  retinal  vessels  remain 
normal ;  there  may  be  some  small  hemorrhages,  and  sometimes 
the  papilla  is  redder  than  normal.  These  appearances  com- 
pletely disappear  in  the  course  of  a  few  days.  Vision  is  only 
slightly  affected  and  recovers  according  as  the  retinal  changes 
pass  off. 

Hyper aesthesia  of  the  Retina. — The  symptoms  of  this  affection 
are  photophobia,  lachrymation,  and  blepharospasm  when  the 
patient  is  exposed  to  ordinary  daylight.  There  are  no  Ophthal- 
moscopic Sig)is.     The  chief  causes  are  hysteria,  long-continued 


388  DISEASES   OF   THE    EYE. 

use  of  the  eyes  with  very  bright  objects,  and  neuralgia  of  the 
fifth  pair. 

Treatment  consists  in  removal  of  the  cause,  rest  of  the  eyes, 
and  protection  from  light,  with  suitable  measures  for  the  general 
health. 


CHAPTER  XVI. 

DISEASES   OF   THE    OPTIC   NERVE. 

Optic  Neuritis. —  The  Ophihalmoscopie  Appearances  of  inflam- 
mation of  the  optic  nerve  vary  a  good  deal  with  the  intensity  of 
the  process.  Common  to  every  case  is  hypersemia  and  swelling 
of  the  papilla,  with  haziness  ("  woolly  "  appearance)  of  its  mar- 
gins, and  increase  in  the  size  of  the  central  vein,  while  the 
central  artery  remains  of  normal  dimensions  or  is  contracted. 
The  swelling  and  haziness  extend  but  a  short  distance  into  the 
surrounding  retina,  and  the  distention  of  the  vein  is  also  not 
continued  to  the  periphery  of  the  fundus.  In  slight  cases  these 
appearances  may  barely  exceed  the  normal. 

In  extreme  instances  the  papilla  is  swollen  to  a  great  size,  and 
may  even  assume  quite  a  mushroom  shape,  while  the  veins  are 
enormously  distended  and  tortuous,  and  the  arteries  are  con- 
tracted so  as  to  be  barely  visible.  Grayish  strise,  also,  extend 
from  the  papilla  into  the  surrounding  retina,  some  flame-shaped 
hemorrhages  are  present  on  or  near  the  papilla,  and,  occa- 
sionally, white  spots  in  the  retina  and  a  stellate  arrangement 
of  small  white  dots  about  the  macula  lutea  produce  an  appear- 
ance which  cannot  be  distinguished  from  albuminuric  retinitis. 
This  extreme  form  is  still  sometimes  termed  Congestion  Papilla, 
or  Choked  Disc  (Stauungspapille'),  although  the  theory  which 
originally  suggested  the  term  has  been  abandoned.  Papillitis 
(Inflammation  of  the  Optic  Papilla)  is  a  better  term,  express- 
ing, as  it  does,  more  truly  the  pathological  condition. 

The  Vision,  even  in  cases  where  the  ophthalmoscopic  signs  are 
highly  developed,  is  frequently  but  little  below  the  normal ; 
while  again  in  other,  and  possibly  less  well-marked  cases,  it 
may  be  reduced   to  perception  of  light,  or  even  that  may  be 

389 


390  DISEASES   OF   THE   EYE. 

wanting.  These  remarkable  differences  in  the  degree  of  blind- 
ness depend,  probably,  on  the  extent  to  which  the  nervous 
elements  of  the  inflamed  part  are  pressed  on  or  altered,  and 
this  cannot  be  gauged  by  the  ophthalmoscopic  appearances. 

Sometimes  the  field  of  vision  is  normal,  while  again  it  is 
concentrically  or  irregularly  contracted,  or  it  may  be  hemi- 
anopic. 

Pathologically,  the  changes  in  the  papilla  consist  in  venous 
hypersemia,  oedema,  hypertrophy  of  the  nerve  fibres,  infiltration 
of  lymph  cells,  and  development  of  connective  tissue.  Inflam- 
matory changes,  although  less  pronounced,  are  also  present  in 
the  trunk  of  the  nerve  and  its  sheaths. 

Causes. — Inflammation  of  the  optic  nerve  is  most  commonly 
found  in  connection  with  coarse  encephalic  disease.  A  Cerebral 
Tumor  (syphiloma,  tubercle,  glioma,  cyst,  and  abscess),  in  par- 
ticular, is  the  most  common  cause,  and  is,  moreover,  usually 
present  when  the  papillitis  is  of  an  intense  kind  (choked  disc)* 
A  very  small  tumor  situated  anywhere"^  in  the  brain  is  capable 
of  producing  optic  neuritis,  although  unattended  by  meningitis. 

Tubercular  Meningitis  is  the  next  most  common  cause.  Non- 
tubercular  meningitis  occasionally  gives  rise  to  optic  neuritis, 
and  sometimes,  also,  cerebro-spinal  meningitis  does  so. 

Optic  neuritis  is  occasionally  associated  with  acute  myelitis,t 
so  that  inflammation  of  the  optic  nerve,  with  paralytic  phe- 
nomena, does  not  exclusively  indicate  cerebral  disease. 

The  Connection  between  Optic  Neuritis  and  Intracranial 
Diseases  has  given  rise  to  much  discussion.  In  cases  of 
tumor,  as  well  as  of  tubercular  meningitis,  a  considerable 
exudation  of  fluid  usually  takes  place  into  the  cavity  of  the 
third   ventricle.      This,   along   with    the   pressure   of   the   new 

'^  Hughlings  Jackson  {Trans.  Ophthal.  Soc,  vol.  i,  p.  79),  states  that 
optic  neuritis  has  not  been  noted  with  tumors  of  the  medulla  oblongata. 
Edmunds  and  Lawford  {Trans.  Ophthal.  Soc,  vol.  iv,  p.  18.5)  find  that 
tumors  of  the  cortical  motor  area  do  not  commonly  produce  neuritis,  while 
it  is  very  frequent  and  severe  in  tumors  of  the  cerebellum. 

t  Sharkey  and  Lawford,  Trails.  Ophthal.  Soc,  iv,  232. 


THE    OPTIC    NERVE.  391 

growth,  or  alone  in  cases  of  meningitis,  increases  the  intra- 
cranial pressure.  By  reason  of  this  increased  pressure,  the 
subarachnoid  fluid  is  believed  to  be  driven  into  the  subvaginal 
lymph  space  of  the  optic  nerve,  and  to  produce  there  that  dropsy 
of  the  sheath  which  is  found  in  nearly  all  these  cases  on  careful 
post-mortem  examination. 

Leber  holds'^  that  this  fluid  is  probably  an  irritant,  and,  as 
such,  sets  up  the  inflammation,  a  view  which  has  been  corrobo- 
rated by  Deutschmann.f 

The  inflammation,  although  most  intense  at  the  papilla,  near 
which  the  fluid  is  collected  in  greatest  quantity  in  the  cul-de-sac 
formed  by  the  termination  of  the  intervaginal  spaces,  is  not 
confined  to  that  place,  as  was  believed,  but  extends  up  the 
trunk  of  the  nerve,  as  microscopic  examination  reveals. 

Many  observerst  state  that,  in  a  large  number  of  cases,  cere- 
britis,  recognizable  only  with  the  microscope,  is  present,  and 
that  an  extension  of  this  process  down  the  optic  nerve  takes 
place.  They  have  ascertained  that  the  whole  trunk  of  the 
nerve  is  involved  in  the  inflammation,  and  they  seem  to  regard 
the  dropsy  of  the  sheath  as  of  little  or  no  importance  in  the 
causation  of  the  optic  neuritis. 

Again,  others§  maintain  that  oedema,  but  not  inflammation, 
of  the  optic  trunk  is  conducted  from  the  brain. 

The  view  originated  by  von  Graefe,  that  the  extreme  form  of 
papillitis,  called  by  him  Stauungspapille  (Choked  Disc),  is  due 
to  obstructed  outflow  of  blood  through  the  retinal  vein,  is  now 
abandoned. 

Other  causes  for  Optic  Neuritis  are  : — 

Hydrocephalus. — Here  the  pathogenesis  is  probably  the  same 

*  Trans.  Inter.  Med.  Congress,  1881,  vol.  iii,  p.  52. 

t  "Ueber  Neuritis  Optica"  (Jena,  1887). 

X  S.  Mackenzie,  Brain,  vol.  ii,  p.  257.  W.  Edmunds,  Trans. 
Ophthal.  Sac,  vol.  i,  p.  112.  Brailey,  Trans.  Internat.  Med.  Congress, 
1881,  vol.  iii.  p.  111. 

I  Olrich,  Archives  of  Ophthal.,  xviii,  p.  65. 


392  DISEASES   OF   THE   EYE. 

as  in  the  foregoing,  but  the  occurrence  of  optic  neuritis  is,  on  the 
whole,  not  very  common  in  this  connection. 

Tumors  of  the  Orbit. — The  path  by  which  these  growths  bring 
about  papillitis  is  still  unknown. 

Inflammatory  Processes  in  the  Orbit,  such  as  caries,  inflam- 
mation of  the  retro-orbital  areolar  tissue,  erysipelas  of  the  head 
and  face  extending  to  the  orbital  tissues,  and  periostitis.  The 
presence  of  the  latter  may  often  be  recognized  by  pain  on  motion 
of  the  eyeball,  pain  in  the  eye  and  forehead,  and  especially  by 
pain  on  pressure  of  the  globe  backward,  and  is  frequently  of 
rheumatic  origin.  Often  in  these  cases  one  eye  only  is  affected, 
and  although  the  Ophthalmoscopic  Appearances  are  sometimes  very 
slight,  yet  vision  may  be  quite  lost  in  a  few  hours  or  days, 
atrophy  of  the  nerve  then  rapidly  setting  in. 

Very  many  of  the  cases,  however,  do  not  go  on  to  atrophy,  but 
end  in  recovery  of  useful  vision. 

Exposure  to  Cold,  especially  if  the  skin  be  heated  and  per- 
spiring. 

Suppression  of  the  Menstruation. — If,  during  the  menstrual 
period,  the  flow  be  arrested  by  exposure  to  col-d,  wet  feet,  etc., 
acute  optic  neuritis  with  rapid  blindness  may  come  on.  Spon- 
taneous amenorrhoea,  or  even  irregularity  of  menstruation,  and 
the  climacteric  period  are  liable  to  have  a  similar,  but  more 
chronic,  result.  Nothing  is  definitely  known  with  regard-  to  the 
connection  between  the  uterine  and  ocular  disorder,  but  it  is 
believed  that  the  latter  is  due  to  "  determination  of  blood  " 
taking  place  to  the  base  of  the  brain,  instead  of  to  the  uterus.  In 
these  cases  the  Ophthalmoscopic  Appearances,  as  well  as  the  blind- 
ness, are  apt  to  be  extreme.  Treatment  here  should  be  directed 
chiefly  to  restoring  the  normal  uterine  functions.  Hot  foot-baths 
and  Heurteloup's  leech  to  the  temples  are  of  use. 

Chlorosis. — Here  optic  neuritis  often  is  present,  due  to  the  dis- 
ordered state  of  the  blood,  and  usually  yields  under  the  influence 
of  iron. 

Syphilis. — The  trunk  of  one  or  both  optic  nerves  may  be  the 
seat  of  specific  inflammation  in  connection  either  with  congenital 


THE   OPTIC    NERVE.  393 

or  with  acquired  syphilis,  but  this  primary  specific  optic  neuritis 
is  a  relatively  rare  disease.  In  cases  of  acquired  syphilis  it 
makes  its  appearance  in  from  six  months  to  two  years  after 
the  inoculation. 

The  Ophthalmoscopic  Appearances  maybe  normal  (retro-bulbar 
neuritis),  or  may  present  any  grade  of  neuritis,  even  to  the  most 
pronounced  papillitis.  In  the  latter  case  it  \yould  not  be  possible 
to  say  whether  the  papillitis  be  a  primary  one,  or  due  to  a 
syphilitic  gumma  within  the  cranium.  The  inflammation  often 
extends  as  far  up  as  the  chiasma. 

The  Treatment  in  these  cases  of  specific  papillitis  must  be 
active  mercurialization.  By  this  treatment,  even  if  perception 
of  light  be  lost  for  a  period  of  not  more  than  eight  to  fourteen 
days,  hopes  may  be  entertained  of  its  complete  or  partial 
recovery.     Later  on,  iodide  of  potassium  is  indicated. 

But,  as  a  rule,  some  optic  atrophy,  at  the  least,  with  slight 
concentric  contraction  of  the  field,  results.  The  prognosis  is 
all  the  better  the  sooner  the  optic  neuritis  follows  upon  the 
primary  syphilitic  affection. 

Rheumatism. — There  is  no  doubt  whatever  but  that  the 
rheumatic  diathesis  is  occasionally  the  cause  of  optic  neuritis, 
although  the  fact  is  not  unreservedly  accepted  by  every  author. 
Other  manifestations  of  rheumatism  are  sometimes  well  marked, 
but  may  be  slight,  e.  g.,  in  a  case  which  I  saw,  neuralgia  of  the 
face  and  head  in  damp  weather,  and  even  with  a  shower  of  rain, 
was  the  only  other  sign  of  rheumatism.  One  or  both  optic 
nerves  may  be  attacked. 

The  Opjhthalmoscopic  Appearances  often  amount  to  extreme 
papillitis,  but  in  many  cases  fall  short  of  this. 

If  the  case  come  early  under  suitable  treatment,  the  Prognosis 
is  fairly  favorable ;  but  when  the  inflammation  is  of  some  stand- 
ing, consecutive  optic  atrophy  must  be  feared. 

The  Treatment  consists  of  full  doses  of  salicin,  salicylate  of 
sodium,  iodide  of  potassium  or  of  sodium,  Turkish  baths,  and 
other  recognized  anti-rheumatic  measures. 

Lead-Poisoning. — In  some  cases  of  lead-poisoning,  optic  neu- 


394  DISEASES   OF   THE   EYE. 

ritis,  not  to  be  distinguished  from  that  of  primary  cerebral 
affections,  is  found.  Sometimes  the  Ophthalmoscopic  Appear- 
ances are  very  slight,  and  again  quite  pronounced,  the  changes 
extending  into  the  retina,  and  stimulating  the  retinitis  of 
Bright's  disease,  and,  in  such  cases,  renal  disease  is  likely  to 
have  much  to  do  with  the  causation  of  the  retinitis.  Indeed, 
there  are  those  who,  w^ith  good  opportunities  for  forming  a 
correct  opinion,  deny  the  existence  of  a  specific  lead  neuritis, 
and  hold  that  the  neuritic  affection  in  all  such  cases  is  to  be 
referred  to  albuminuria,  to  effusion  into  the  ventricles  of  the 
brain  and  subarachnoid  space,  or  to  suppression  of  menstrua- 
tion. Occasionally,  optic  atrophy  is  the  first  ophthalmoscopic 
appearance  seen,  but  it  is  probably  consecutive  to  retro-bulbar 
neuritis,  as  shown  by  white  strise  (perivascularitis)  along  the 
vessels. 

The  Vision  is  often  much  affected,  and  it  is  stated  that  sudden 
complete  blindness  in  connection  with  an  intercurrent  attack 
of  lead  colic  may  appear  and  pass  off  again.  Consecutive 
atrophy  is  liable  to  come  on,  and  then  vision  may  be  seriously 
and  permanently  damaged. 

The  Diagnosis  depends  entirely  on  the  presence  of  the  other 
well-known  symptoms  of  lead-poisoning,  the  ophthalmoscopic 
appearances  presenting  nothing  pathognomonic. 

The  Treatment  is  that  for  general  lead-poisoning,  or  for  the 
immediate  cause  of  the  neuritis. 

Multiple  Sclerosis. — In  these  cases  the  inflammation  is  very 
ephemeral,  and  rapidly  gives  place  to  atrophy.  Uhthoff  states 
that  it  occurs  in  about  13  per  cent,  of  the  cases  of  this  disease. 

Hereditary  and  Congenital  Predisposition. — It  has  been 
observed  that  optic  neuritis,  without  immediate  cause,  may 
attack  several  members  of  a  family,  and  that  the  tendency  to 
it  may  extend  over  several  generations.  Jt  makes  its  appear- 
ance in  these  instances  about  the  eighteenth  or  twentieth  year 
of  age,  and  confines  itself  almost  exclusively  to  the  males.  The 
patients  may  be  perfectly  healthy  in  all  other  respects,  but 
many  of   them   suffer   from   other   affections    of   the   nervous 


THE   OPTIC   NERVE.  395 

system.  Both  eyes  are  affected,  the  defect  of  vision  being  a 
central  amblyopia,  from  which  recovery  is  rare ;  but  yet, 
although  the  ophthalmoscopic  appearances  gradually  become 
those  of  atrophy,  the  peripheral  portions  of  the  field  retain 
their  functions. 

As  to  the  Treatment  of  these  cases  due  to  hereditary  and 
congenital  predisposition,"^  Mooren  employs  a  seton  in  the  back 
of  the  neck  in  the  early  periods,  and,  later  on,  nitrate  of  silver 
internally.  Leber  has  found  benefit  from  a  mild  course  of 
mercurial  inunctions. 

The  two  following  diseases.  Chronic  Ketro-bulbar  Neuritis,  or 
Central  Amblyopia,  and  Optic  Neuritis  with  Persistent  Dropping 
from  the  Nostril,  must  be  treated  of  separately,  owing  to  the  well- 
defined  etiology  of  the  one  and  the  peculiar  symptoms  of  the 
other. 

Chronic  Retro-bulbar  Neuritis,  or  Central  Amblyopia  (Toxic 
Amblyopia). — Until  within  recent  years,  it  was  not  clearly 
known  whether  these  two  terms  should  be  applied  to  one  and 
the  same  disease,  or  whether  we  had  to  deal  here  with  two 
distinct  processes.  There  is  a  class  of  cases  which  were  ad- 
mittedly due  to  an  inflammatory  process  in  the  trunk  of  the 
nerve,  the  causes  and  symptoms  of  which  were  very  similar  to 
those  of  central  amblyopia,  while  there  was  strong  presump- 
tive evidence  that  the  latter  affection,  often  known  as  Toxic 
Amblyopia,  was  due  to  a  retro-bulbar  inflammation  ;.  but  direct 
proof  of  the  fact  was  wanting.  Thanks  to  late  investigations,"^ 
there  is  now  no  doubt  but  that  we  have  here  to  deal  with  only 
one  disease. 

Symptoms. — The  affection   of  vision   often   comes   on  rather 

*  Mooren,  Ophthal  BerichL,  1867,  p.  305,  and  1874,  p.  87;  and  Funf 
Lustren  Ophthal.  WirJcsamkeit,  1882,  p.  248.  Norris,  Tratis.  Amer. 
Ophthal.  Soc,  1884,  p.  662. 

*  Samelsohn,  A.  v.  Graefes  Archiv,  xxviii,  pt.  1,  p.  1.  Nettleship 
and  Walter  Edmunds,  Trans.  Ophthal.  Soc,  vol.  i,  p.  124.  Uhthoff, 
von  Graefes  Archiv,  xxxii,  p.  4.  Sachs,  Archiv  of  Ophthal,  xviii, 
p.  133. 


396  DISEASES   OF   THE   EYE. 

rapidly.  The  patient  may  complain  of  a  glimmering  mist  which 
covers  all  objects,  especially  in  a  bright  light,  and  the  acuteness 
of  vision  is  reduced.  The  patient  generally  states  he  can  see 
better  in  the  dusk  than  in  bright  light.  At  the  commencement 
there  is  no  defect  in  the  field  of  vision,  but  simply  a  general  dim- 
ness of  vision.  At  a  somewhat  later  stage  examination  of  the 
field  discovers  no  defect  for  a  white  object,  yet  if  a  small,  pale- 
green  object  be  employed,  it  will  generally  be  ascertained  that, 
at  a  region  close  to  the  point  of  fixation,  the  color  is  not  recog- 
nized, but  seems  gray  or  white ;  pink  may  seem  blue  and  red 
may  appear  brown  or  black,  while  in  other  parts  of  the  field  the 
colors  are  recognized  up  to  their  normal  boundaries.  This  is  a 
central  color-scotoma.  As  the  disease  advances  a  white  object 
will  be  but  indistinctly  seen  in  the  scotoma,  and,  in  some  rare 
cases,  all  power  of  perception  within  its  area  may  be  lost,  even 
the  flame  of  a  candle  not  being  recognized.  Hence  the  name 
Central  Amblyopia.  The  scotoma  is  usually  oval  in  shape,  its 
long  axis  horizontal,  and  extends  from  the  fixation-point  toward 
the  blind- spot  of  Mariotte  (paracentric  scotoma);  but  occasion- 
ally it  is  of  much  larger  dimensions  and  sometimes  surrounds 
the  fixation  point  (pericentric  scotoma). 

Even  when  the  scotoma  is  very  pronounced  it  remains  "  rela- 
tive," i.  e.,  it  is  not  observed  by  the  patient  as  a  dark  spot  in  the 
field,  as  is  a  scotoma  due  to  disease  in  the  outer  retinal  layers 
(p.  372).  The  affection  is  almost  always  binocular,  and,  as  a  rule, 
there  is  but  little  difference  between  the  vision  of  the  two  eyes. 

The  Progress  of  the  disease  is  slow,  occupying  weeks  or  months. 
Restoration  of  normal  vision  usually  takes  place  if  the  defect  of 
vision,  although  of  extreme  degree,  be  not  of  old  standing.  In 
the  latter  case,  while  recovery  of  central  vision  cannot  be  ex- 
pected, the  functions  in  the  periphery  of  the  field  are  usually 
maintained,  and,  consequently,  these  people,  although  incapaci- 
tated from  reading,  writing,  and  other  fine  work,  do  not  lose 
their  power  of  guiding  themselves. 

Causes. — With  but  few  exceptions,  the  subjects  of  this  disease 
are  men,  probably  because  their  habits  and  modes  of  life  expose 


THE    OPTIC    NERVE.  397 

them  more  than  women  to  the  influences  which  produce  it. 
These  are  exposure  to  cold  and  wet;  cold  blasts  on  the  body, 
especially  the  heated  face  (Samelsohn)  ;  but  the  most  common 
cause  is  excess  in  the  use  of  alcohol  or  of  tobacco  (toxic  ambly- 
opia), or  of  both.  I  think  the  kind  of  alcoholic  indulgence 
most  likely  to  develop  the  disease  is  the  frequent  drinking  of 
small  doses  of  the  stimulant.  The  individual  who  often  gets 
thoroughly  drunk,  and  between  times  drinks  but  little,  is  less 
liable  to  central  amblyopia  than  he  who,  although  never  inca- 
pable of  transacting  his  business,  takes  many  half-glasses  of 
whisky  or  brandy  during  the  day.  Dyspepsia  and  loss  of  appe- 
tite are  constantly  present  in  these  cases.  Other  signs  of  chronic 
alcoholism  need  not  be  present,  but  one  often  sees  trembling  of 
the  hand  and  head,  sleeplessness,  and  even  delirium  tremens. 
The  kind  of  tobacco  most  likely,  when  used  in  excess,  to  give  rise 
to  central  amblyopia,  is  shag  or  twist.  Other  kinds  of  pipe-to- 
bacco and  cigars  may  cause  it,  but  I  have  not  known  of  a  case 
due  to  cigarette-smoking. 

Excess  in  alcohol  is  usually  combined  with  excessive  smoking, 
but  cases  of  pure  alcohol- amblyopia  certainly  do  occur — al- 
though some  English  authors  deny  it — as  well  as  pure  tobacco- 
amblyopia.  The  most  common  age  for  tobacco-amblyopia  is 
from  thirty-five  to  fifty,  a  time  of  life  when  men  do  well  to  give 
up  or  to  very  much  reduce  their  use  of  tobacco  as  well  as  of 
alcohol. 

Central  amblyopia  has  also  been  observed  in  diabetes,  and  in 
poisoning  from  bisulphide  of  carbon,"^  so  largely  used  in  the 
manufacture  of  india-rubber. 

Retro-bulbar  neuritis  very  occasionally  attends  disseminated 
sclerosis,  with  atroj^hy  of  the  temporal  side  of  the  papilla ;  but 
yet  central  scotoma  is  not  always  present. 

The  Ophthalmoscopic  Appearances  in  the  beginning  are  either 
quite  normal  or  there  is  slight  hypersemia  of  the  papilla  and 
retinal  vessels ;  or,  in  addition,  there  may  be  slight  indistinctness 

*  Trans.  Ophth.  Soc,  vol.  v,  p.  149. 


398  DISEASES   OF   THE    EYE. 

of  the  margins  of  the  papilla,  and  sometimes  white  striae  along 
the  vessels,  especially  before  they  leave  the  papilla.  All  the 
primary  appearances,  if  any  be  present,  soon  pass  away,  and  give 
place  to  a  grayish  whiteness  of  the  temporal  side  of  the  papilla, 
while  the  nasal  portion  remains  of  normal  appearance,  as  do  also 
the  vessels.  At  a  very  advanced  stage,  in  some  cases,  the  whole 
papilla  presents  the  appearance  of  white  atrophy. 

The  Pathological  Changes  observed  by  Samelsohn,  Nettleship 
and  Walter  Edmunds,  and  UhthofF  in  the  optic  nerve  consist 
of  an  interstitial  neuritis  at  its  axis,  commencing  so  high  up  as 
the  optic  foramen,  and  leading  to  proliferation  of  connective- 
tissue  and  to  secondary  descending  atrophy  of  a  certain  bundle 
of  nerve  fibres.  These  are  doubtless  the  fibres  which  supply  the 
region  of  the  macula  lutea.  The  changes  are  analogous  to  those 
which  take  place  in  the  liver  and  brain  as  the  result  of  chronic 
alcoholism. 

Treatment  consists,  above  all,  in  total  abstinence  from  the  poison 
in  question.  The  patients  are  generally  ready  to  promise  this,  but 
they  often  do  not  act  up  to  their  intentions.  When  they  do  so, 
improvement  rapidly  takes  place  in  most  cases  which  are  not 
too  far  gone,  without  any  other  treatment ;  but  the  cure  may  be 
promoted  by  the  use  of  iodide  of  potassium  in  large  doses,  Heurte- 
loup's  artificial  leech  or  dry  cupping  to  the  temples,  hot  foot- 
baths, and  Turkish  baths.  Strychnine  hypodermically  (-^-^  grain 
daily)  in  the  temple  is  often  of  use,  and  phosphorus  and  strych- 
nine may  be  given  internally.  Whatever  remedy  be  used  inter- 
nally, care  should  be  taken  that  it  does  not  produce  or  increase 
dyspepsia,  and  it  may  be  necessary  to  restrict  the  internal  medi- 
cine for  a  time,  or  altogether,  to  a  stomachic  tonic.  Sleepless- 
ness should  be  combated  with  chloral  and  bromide  of  potassium. 
Treatment  may  have  to  be  continued  for  some  weeks  before  a 
cure  can  be  noted. 

Optic  Neuritis  Associated  with  Persistent  Dropping  of 
Watery  Fluid  from  the  Nostril. — Nettleship  *  (one  case),  Priest- 

*  Ophthal.  Rev.,  1883,  p.  1. 


THE    OPTIC    NERVE.  399 

ley  Smith*  (two  cases),  Leber  f  (one  case),  and  Emrys  Jones  J 
(one  case),  have  placed  on  record  five  well-observed  cases  of  this 
remarkable  disorder,  and  three  others  have  been  observed  by 
Elliotson,  Baxter,  and  Paget.  These  patients  suffered  from  a 
persistent  watery  discharge  from  the  nose  (usually  the  left  nos- 
tril), with  more  or  less  severe  cerebral  symptoms — violent  head- 
ache, epileptic  attacks,  vomiting,  stupidity,  sleepiness,  uncon- 
sciousness, delirium,  weakness  of  the  lower  extremities,  and  a 
high  degree  of  amblyopia,  or  even  blindness,  of  both  eyes,  due  to 
papillitis  followed  by  atrophy.  In  Leber's  case,  moreover,  there 
was  loss  of  smell,  and  in  Nettleship's  case  palpitation  of  the  heart 
and  prominence  of  the  eyes.  The  fluid  which  ran  from  the  nos- 
tril was,  according  to  Leber,  identical  in  its  analysis  with  that  of 
the  cerebro-spinal  fluid, while  Nettleship  and  Priestley  Smith  found 
it  to  differ  somewhat  from  that  fluid.  When,  in  P.  Smith's  case, 
it  occasionally  ceased  to  flow,  the  cerebral  symptoms  were  brought 
on,  or  increased  in  violence.  Leber's  case  was  one  of  internal 
hydrocephalus,  and  he  regards  the  fluid  as  coming  from  the 
third  ventricle  through  a  small  opening  in  the  ethmoid  bone ; 
or  the  fluid  possibly  passed  from  the  subdural  space  along  the 
lymph  spaces,  which,  according  to  Axel  Key  and  Retzius,  sur- 
round the  olfactory  nerves.  But  Priestley  Smith  and  Nettleship 
considered  the  fluid  as  simply  nasal,  and  due  to  the  presence  of 
small  polypi,  and  did  not  try  to  account  for  its  occurrence  in 
connection  with  the  cerebral  and  ocular  symptoms.  The  first  of 
these  two  views  is  probably  the  correct  one. 

The  Prognosis  for  vision  is  bad,  while  the  cerebral  affection 
threatens  even  the  life  of  the  patient. 

Treatment,  which  should  be  in  conformity  with  the  head 
symptoms,  has  not  proved  of  use. 

Atrophy  of  the  Optic  Nerve. — This  disease,  may  be  secondary 
to  some  other  optic  nerve  or  retinal  affection,  or  it  may  be  a 

^  Ophthal.  Rev.,  1883,  p.  4. 

t  A.  V.  Graefes  Archiv,  xxix,  pt.  1,  p.  271. 

X  Meeting  British  Med.  Assoc,  Dublin,  1887. 


400  DISEASES    OF   THE    EYE. 

primary  disease.  The  vision  is  seriously  affected,  and  complete 
blindness  is  the  usual  result.  With  the  ophthalmoscope  the  optic 
papilla  is  seen  to  have  lost  its  delicate  pink  color  and  to  have 
become  white  or  grayish,  while  it  is  often  cupped,  and  the  vessels 
are  apt  to  be  diminished  in  calibre. 

Secondary  Atrophy  of  the  Optic  Xerve  may  result : — 

1.  From  Optic  Xeuritis. — The  ophthalmoscopic  appearances 
consist  in  a  white  or  grayish-white  color  of  the  papilla,  with 
very  diminished  retinal  vessels,  and  along  both  sides  of  the 
vessels,  far  into  the  retina,  are  seen  white  lines,  which  some- 
times even  obscure  the  vessels,  and  which  are  due  to  hyper- 
trophy of  their  coats.  The  diminution  in  calibre  of  the  vessel 
is  a  sign  of  ueuritic  atrophy,  but  is  not  always  present,  and  is 
moreover  found  with  other  forms  of  atrophy.  Other  signs  of 
this  form,  also  not  constant,  are :  a  certain  opacity  of  the 
papilla,  and  that  the  lamina  cribrosa  is  not  generally  visible, 
owing  to  development  of  connective  tissue  at  the  papilla.  It 
is,  evidently,  not  always  possible  to  recognize  any  given  case  as 
of  neuritic  origin. 

Symptoms. — Central  vision  is  lowered,  and,  as  a  rule,  the  field 
of  vision  becomes  contracted,  usually  more  at  the  nasal  side. 
Subsequently,  the  temporal  side  of  the  field  becomes  contracted, 
and  finally  a  small  eccentric  portion  of  the  field  to  the  temporal 
side  may  be  all  that  remains,  or  even  this  may  disappear  and 
absolute  amaurosis  result.  The  color-vision  is  always  much 
aflTected.  The  light-sense  is  aflfected,  so  that  there  is  dimin- 
ished sensibility  for  diflferences  of  illumination  ;  w^hile,  in  cho- 
roido-retinal  diseases,  there  is  defect  in  the  quantitative  percep- 
tion of  light,  the  minimum  quantity  being  larger  than  normal.* 

2.  From  Pressure. — This  may  be  brought  about  by  a  tumor 
anywhere  in  the  course  of  the  nerve,  by  inflammatory  exuda- 
tions, by  a  splinter  of  bone  in  cases  of  fracture  of  the  skull, 
and  also  by  pressure  upon  the  chiasma  by  the  floor  of  the 
distended  third  ventricle,  in  cases  of  internal  hydrocephalus. 

*  Bjerrum,  F.  Graefe's  Archiv,  xxx,  pt.  2,  p.  201. 


THE    OPTIC    NERVE.  401 

3.  From  Embolism  of  the  Central  Artery  of  the  Retina. — In 
these  cases  the  contraction  of  the  vessels  is  usually  extreme. 

4.  From  Syphilitic  Retinitis,  Retinitis  Pigmentosa,  and  Cho- 
roido-retinitis.  The  vessels  here  are  much  attenuated,  and  the 
altered  color  of  the  optic  disc  is  a  dull  yellow,  rather  than 
white  or  gray. 

Primary  Optic  Atrophy  is  often  found  associated  with  Disease  of 
the  Spinal  Cord  (Spinal  Amaurosis),  especially  locomotor  ataxy. 
Optic  atrophy  is  often  an  early  symptom  in  the  latter  disease  ; 
but,  again,  it  may  not  come  on  until  the  affection  of  the  gait  is 
well  pronounced,  while  in  other  cases  it  is  never  present  at  all. 
It  is  a  remarkable  and  important  fact,  first  pointed  out  by 
Benedikt,  of  Vienna,  that  there  is  an  antagonism  between 
atrophy  of  the  optic  disc  and  the  other  symptoms  of  tabes 
dorsalis.  It  is  rare  for  a  tabetic  patient,  in  whom  optic 
atrophy  comes  on  in  an  early  stage  of  his  disease,  to  become 
ataxic ;  and  frequently,  in  these  cases,  when  the  blindness  has 
advanced,  the  pains,  too,  become  less  severe.  But,  if  amaurosis 
does  not  come  on  until  the  ataxy  is  well  developed,  no  improve- 
ment in  the  latter  is  likely  to  be  noted. 

Atrophy  is,  more  rarely,  found  with  insular  sclerosis  and 
lateral  sclerosis  of  the  spinal  cord  ;  and  in  general  paralysis  of 
the  insane,  although  spinal  disease  is  not  always  present,  atrophy 
of  the  papilla  frequently  occurs. 

It  is  probable  *  that  the  disease  commences  at  the  papilla  in 
spinal  cases.  The  ophthalmoscope  displays  a  papery-white  or 
bluish-white  papilla,  which,  in  advanced  stages,  often  becomes 
cupped.  The  retinal  arteries  are  usually  extremely  reduced  in 
calibre,  and  the  veins,  too,  may  be  small ;  but,  again,  the  retinal 
vessels  may  differ  but  little  or  not  at  all  from  the  normal. 

Symptoms. — Central  vision  is  affected  at  an  early  stage  in  the 
disease,  and  eccentric  contraction  of  the  field  usually  appears  at 
the  same  time.  The  contraction  may  be  concentric  or  it  may  be 
more  marked  in  one  direction  than  another,  and   opinion  is 


*Nettleship,  Trans.  Ophthal.  Soc,  1883,  p.  249, 
34 


402  DISEASES   OF   THE   EYE. 

divided  as  to  the  direction  commonly  first  involved.  This 
concentric  contraction  advances  gradually  toward  the  centre 
of  the  field  from  every  side  until  it  finally  engulfs  the  fixation 
point. 

Occasionally  the  affection  begins  as  a  central  scotoma  accom- 
panied by  eccentric  defects  of  the  field.  Color-blindness  is  an 
almost  constant  symptom.  As  a  rule,  absolute  blindness  is 
brought  about  in  the  course  of  a  year  or  two. 

Primary  Optic  Atrophy,  of  the  progressive  form  just  described, 
may  occur,  as  a  Purely  Local  Disease,  without  any  other  defect 
in  the  system.  The  prognosis  for  the  sight  in  such  cases  is  as 
bad  as  in  spinal  cases. 

Treatment. — In  neuritic  atrophy,  so  long  as  there  are  still 
signs  of  active  inflammation,  antiphlogistic  measures— Heurte- 
loup's  leech  to  the  temple,  hot  foot-baths,  rest  of  body  and  mind, 
dark  room,  iodide  of  potassium,  and,  especially,  mercury  inter- 
nally, when  otherwise  admissible — are  to  be  adopted.  At  a 
later  period  hypodermic  injections  of  strychnia  (3-^  gr.,  increased 
gradually  to  2V  ^^  tt  S^-  ^^^^  ^  ^^j)  ^^^  galvanism  may  be 
tried. 

In  special  amaurosis  and  in  optic  atrophy  occurring  as  a  local 
disease,  strychnia  hypodermically  and  the  galvanic  current 
sometimes  improve  vision  for  a  time.  Phosphorus  internally 
may  be  given. 

The  treatment  for  optic  atrophy  due  to  causes  2,  3,  and  4  is  to 
be  directed  to  the  primary  disease. 

The  Prognosis  is  very  bad,  for  although  every  therapeutic 
measure  may  have  been  employed,  amaurosis  is  the  ultimate 
result,  as  a  rule. 

Tumors  of  the  Optic  Nerve. — These  are  extremely  rare.  The 
chief  forms  are  myxoma,  glioma,  and  gliosarcoma  or  myxo- 
sarcoma. 

The  symptoms  which  von  Graefe  held  to  be  most  characteristic 
of  the  presence  of  a  tumor  of  the  optic  nerve  are:  Increasing 
protrusion  of  the  eyeball  forward  and  outward,  with  retention 
of  its  motion  and  without  displacement  of  its  centre  of  rotation. 


THE    OPTIC    NERVE.  403 

The  tumor  is  soft,  so  that  the  eyeball  can,  as  it  were,  be  pushed 
back  into  it,  and  there  is  no  pain. 

The  growth  of  these  tumors  is  slow.  It  is  sometimes  possible 
to  remove  such  a  tumor,  and  yet  to  preserve  the  eyeball,  by 
dislocating  the  latter  during  the  operation.  As  a  rule,  it  is 
necessary  to  enucleate  the  eyeball  in  order  to  reach  the  tumor, 
and  if  the  growth  have  involved  the  surrounding  orbital  tissues 
these,  too,  must  be  taken  away. 

Hyaline,  or  Colloid  Outgrowths  from  the  optic  papilla,  are 
occasionally  met  with.  They  present  the  appearance  of  bluish- 
gray,  mulberry-like  nodules.  According  to  IwauofF,  ^  they 
originate  in  the  lamina  vitrea  of  the  choroid,  at  the  margin  of 
the  papilla  or  within  the  area  of  the  papilla,  for  the  lamina 
vitrea  is  often  prolonged  into  the  papilla  and  takes  part  in  the 
formation  of  the  lamina  cribrosa.  But  Gurwitschf  disputes  this 
view,  and  states  that  these  growths  spring  from  the  coats  of  the 
vessels  in  the  optic  papilla.  These  outgrowths  do  not  always 
cause  a  defect  of  sight,  and  rarely  cause  serious  blindness.  It 
is  often  found  that  a  blow  upon  the  eye  has  been  received  some 
time  previously,  and  it  is  probable  that  such  a  trauma  may  have 
to  do  with  the  growth  by  rupturing  the  very  brittle  lamina 
vitrea. 

Injuries  of  the  Optic  Nerve. — In  addition  to  those  injuries 
which  result  from  direct  violence  with  sharp  instruments,  etc, 
entering  the  orbit,  the  optic  nerve  may  be  injured  in  falls  on  the 
head.  Fractures  of  the  base  of  the  skull  frequently  involve 
injury  to  the  optic  nerve.  But,  even  where  no  fracture  occurs, 
blindness  with  atrophy  of  the  optic  nerve  may  come  on,  usually 
only  in  one  eye,  and  in  these  cases  concussion  of  the  nerve  at  its 
passage  through  the  optic  foramen,  or  an  extravasation  of  blood 
in  the  sheath  of  the  nerve,  is  probably  the  direct  cause  of  the 
atrophy. 

Glycosuric  Amblyopia. — In  addition  to  the  retinal  affections 

^  Klin.  Monatshl.  f.  Augenhlk.,  vi,  p.  425. 
t  Centralbl.  f.  Augenhlk.,  Aug.,  1891. 


404  DISEASES   OF   THE   EYE. 

dependent  upon  diabetes,  we  recognize  the  occasional  occurrence 
in  that  disease  of  defects  of  vision,  which  are  referred  to  dis- 
order of  the  optic  nerve  and  which  are  not  always  accompanied 
by  ophthalmoscopic  changes.  These  defects  of  vision  are  found 
in  the  form  of:  1.  Central  Amblyopia  (see  p.  397)  or,  in  slighter 
cases,  amblyopia  without  central  scotoma.  Occasionally,  higher 
degrees  of  amblyopia  with  concentric  contraction  of  the  field  of 
vision,  and  yet  negative  ophthalmoscopic  appearances,  are  pres- 
ent. 2.  Atrophy  of  the  optic  nerve.  This  may  appear  in  the 
usual  form  as  progressive  blindness,  with  concentric  contraction 
of  the  field  of  vision,  or  it  may  come  on  after  the  slighter  form 
of  amblyopia  has  existed  for  some  time.  It  is  probable  (Leber) 
that  these  apparently  diflferent  kinds  of  blindness  depend  upon 
similar  pathological  processes  and  merely  indicate  degrees  of  the 
latter.  In  what  these  processes  consist  is  still  unknown,  but  the 
tendency  to  hemorrhages  in  the  retina  in  diabetes  makes  it 
likely  that  hemorrhages  in  the  optic  nerve  are  sometimes  the 
source  of  the  amblyopia  in  question,  while  in  the  cases  with 
central  scotoma  it  is  no  doubt*  due  to  retro-bulbar  neuritis 
similar  to  that  produced  by  tobacco,  etc. 

Amblyopia  is  sometimes  the  only  symptom  of  diabetes,  and, 
consequently,  as  Leber  points  out,  it  is  of  the  utmost  importance 
to  examine  the  urine  for  sugar  in  every  case  of  amblyopia  where 
the  ophthalmoscopic  appearances  are  negative,  or  where  the  only 
abnormality  is  atrophy  of  the  optic  papilla. 

The  Treatment  indicated  is  solely  that  for  the  general  disease, 
and  the  prognosis  for  vision  depends  upon  the  amenability  of  the 
latter  to  treatment  and  upon  the  extent  to  which  organic  changes 
in  the  optic  nerve  have  gone.  Hirschberg  f  inclines  to  the  view 
that  diabetic  amblyopia  constitutes  a  serious  symptom  for  the 
life  of  the  patient. 

Hemorrhages  from  the  Stomach,  Bowels,  or  Uterus  are  capa- 
ble of  giving  rise  to  serious  and  incurable  blindness. 

*  Nettleship  and  Edmunds,  Trans.  Ophthal.  Soc,  vol.  i,  p.  124. 

t  Ceatralbl.  f.  Augenheilk,  1886,  p.  199. 


THE    OPTIC    NERVE.  405 

Blindness  during  or  immediately  after  a  severe  hemorrhage 
is  probably  due  to  insufficient  blood-supply  to  the  nerve-centres 
and  retina,  accompanying  general  exhaustion  of  the  system. 
For  such  cases  the  prognosis  is  favorable. 

But  there  is  another  class  of  cases  of  very  much  more  serious 
import.  In  these  the  defect  of  vision  does  not  come  on  for  from 
two  to  fourteen  days  after  the  hemorrhage,  when  the  general 
system  is  recovering.  Even  comparatively  slight  hemorrhages, 
which  caused  no  marked  anaemia,  are  said  to  have  been  followed 
by  blindness.  The  connection  between  the  loss  of  blood  and  of 
sight  in  these  cases  is  not  yet  clearly  madie  out.  Leber  inclines 
to  the  belief  that  the  blindness  here  is  due  to  an  extravasation 
of  blood  at  the  base  of  the  skull  and  into  the  sheath  of  the  optic 
nerve,  but  even  then  the  relationship  between  this  and  the 
stomachic  or  uterine  hemorrhage  is  not  made  clearer.  Papillitis 
has  been  several  times  noted  with  the  ophthalmoscope  in  these 
cases,  and  this  circumstance  makes  it  probable  that  neuritis  is 
the  immediate  cause  of  blindness — even  in  those  cases  which 
show  no  ophthalmoscopic  sign  of  it — and  hydrsemia  may  be 
presumed  to  be  the  poisonous  influence  which  calls  forth  the 
neuritis. 

The  Defect  of  Vision  may  be  but  slight,  or  it  may  amount  to 
absolute  amaurosis.  Both  eyes  are  usually  affected  in  equal 
degree,  but  cases  have  been  observed  in  which  one  eye  was  com- 
pletely amaurotic,  while  the  vision  of  the  other  eye  was  quite 
normal,  and  one  such  case  is  sufficient  to  prove  that  the  lesion 
is  peripheral ;  in  fact,  that  it  lies  in  each  instance  on  the  distal 
side  of  the  optic  chiasma.  The  field  of  vision  is  frequently  con- 
tracted either  concentrically  or  segmentally,  and,  even  when 
central  vision  recovers,  the  field  may  remain  contracted. 

The  Ophthalmoscopic  Ajypearances  which  are  present  immedi- 
ately on  the  occurrence  of  the  blindness  have  not  as  yet  been 
observed.  A  few  weeks  later  they  have  been  found  to  be 
different  in  different  cases.  They  have  been  found,  at  this 
period,  normal ;  or  presenting  slight  paleness  of  the  papilla  and 
contraction  of  the  arteries ;  or  there  was  marked  paleness  of  the 


406  DISEASES    OF   THE    EYE. 

papilla,  and  the  arteries  were  extremely  contracted,  with  slight 
distention  of  the  veins ;  or  paleness  of  the  papilla  was  present, 
but  its  margins  were  indistinct  and  the  surrounding  retina  some- 
what swollen,  while  the  retinal  vessels  were  normal.  Small 
hemorrhages  have  repeatedly  been  seen  in  the  neighborhood  of 
the  papilla.  At  later  periods  well-marked  optic  atrophy  is 
frequently  observed. 

Prognosis. — If,  in  the  beginning,  the  defect  of  vision  be  merely 
amblyopia  and  not  complete  blindness,  hopes  may  be  entertained 
of  marked  improvement  or  of  complete  recovery.  But  Mooren 
has  seen  slight  amblyopia  pass  into  permanent  amaurosis. 

Hemorrhages  from  the  stomach  are  those  which  are  followed 
by  the  most  complete  and  permanent  blindness,  while  uterine 
hemorrhages  are  more  commonly  followed  by  less  serious  degrees 
of  blindness. 

The  Treatment  must  consist  of  internal  remedies  calculated  to 
correct  the  general  ansemia,  such  as  iron,  beef  tea  and  meat  ex- 
tracts, wine,  etc.  Strychnine  hypodermically,  to  stimulate  the 
nerve,  may  be  employed. 


CHAPTER  XVII. 

AMBLYOPIA    AND    AMAUROSIS*    DUE    TO    CEN- 
TRAL AND  OTHER  CAUSES. 

Hemianopsia  (j];j.'.fTo^^  half;  a,  priv.;  ax^',  the  eye). — This  term 
implies  a  loss  of  sight  in  one-half  of  the  field  of  vision,  usually 
of  each  eye,  consequent  upon  a  lesion  at  the  centre  of  vision,  at 
the  chiasma,  or  at  some  point  in  the  course  of  the  visual  fibres 
between  these  two  places.  It  is  not  used  for  cases  in  which  one- 
half  of  the  field  is  lost,  owing  to  disease  within  the  eye  itself. 

Fig.  127.  Fig.  128,  Fig.  129. 


The  line  dividing  the  seeing  from  the  blind  half  passes  ver- 
tically down  the  centre  of  the  field,  as  in  Fig.  127.  Sometimes 
this  line  lies  a  little  to  one  side  of  the  centre  of  the  field,  so  as 
to  admit  of  the  latter  being  included  in  the  seeing  part,  as  in 
Fig.  128  ;  and  sometimes — although  in  other  respects  the  divid- 

*  These  terms  have  been  handed  down  to  us  from  the  old  writers. 
Amblyopia  {aupig^  blunt ;  ^v-,  the  eye)  is  nowadays  usually  employed  to 
signify  defective  vision  due  to  disease  or  functional  disturbance  of  the 
retina,  optic  nerve,  or  visual  centre,  but  with  healthy  ophthalmoscopic 
appearances,  or  with  signs  only  of  optic  atrophy.  Amaurosis  {aiuavpog, 
dark)  means  total  loss  of  sight,  with  similar  ophthalmoscopic  appear- 
ances. Yet  the  use  of  these  terms  will  be  found  sometimes  to  exceed 
the  definitions  here  stated. 

407 


408 


DISEASES   OF   THE   EYE. 


ing  line  lies  in  the  centre  of  the  field — the  fixation  point  is  cir- 
cumvented by  it,  so  as  to  leave  that  point  free,  as  in  Fig.  129  ; 
and,  probably,  this  is  the  most  common  arrangement.  This  sub- 
ject will  be  further  discussed  on  p.  410.  Again,  although  rarely, 
the  dividing  line  may  have  an  oblique  direction,  as  in  Fig.  130. 
It  is  probable  that  such  a  field  as  Fig.  130  is  due  to  some 
peculiar  arrangement  in  the  decussation  of  the  nerve  fibres  in 
the  individual  case.  Furthermore,  cases  occur  which  are  prop- 
erly regarded  as  hemianopsia,  and  yet  in  which  only  a  sector  of 
one  side  of  the  field  is  wanting,  as  in  Fig.  131.  Figs.  127,  128, 
129,  and  130  would  be  called  complete  hemianopsia,  while  Fig. 
1 31  would  be  termed  incomplete,  or  partial,  hemianopsia.  Finally, 
if  all  three  visual  perceptions  be  lost,  the  hemianopsia  is  called 


Fig.  130. 


Fig.  131. 


absolute ;  but  if  only  one  (color)  or  two  (color  and  form)  be 
wanting  in  the  defective  part  of  the  field,  it  is  termed  relative 
hemianopsia.  The  vast  majority  of  cases  of  hemianopsia  are 
absolute. 

Homonymous  Hemianopsia  is  the  most  frequent  form.  In  it 
the  corresponding  half — the  right  half  or  the  left  half — of  the 
field  of  each  eye  is  wanting,  as  in  Fig.  132,  in  which  the  left  side 
of  the  fields,  from  the  patient's  point  of  view,  is  blind,  implying 
a  loss  of  function  in  the  right  half  of  each  retina. 

Temporal  Hemianopsia  is  loss  of  vision  in  the  outer  side  of 
each  field,  in  consequence  of  loss  of  power  in  the  median  half 
of  each  retina  (Fig.  133).  It  is  by  no  means  so  common  as  the 
homonymous  form. 

Superior   or   Inferior   Hemianopsia,  also   called   Altitudinal 


AMBLYOPIA    AND    AMAUROSIS. 


409 


Hemianopsia,  iu  which  the  upper  or  lower  half  of  the  field  is 
blind,  is  very  rare,  and  it  is  doubtful  whether  Kasal  Hemian- 
opsia has  really  been  observed,  although  it  has  been  described. 
In  the  latter,  the  inner  side  of  the  field  of  one  eye  only  is  lost, 
owing  to  defective  function  of  the  temporary  side  of  the  retina. 
It  will  be  convenient  here  to  set  forth  the  prevailing  views 


Fig.  182. 


as  to  The  Arrangement  of  the  Cortical  Visual  Centres,  their 
Relations  to  the  Retina,  and  the  Course  of  the  Optic  Fibres  between 
these  tivo  points. 

Pathological  anatomy  leaves  little  doubt  but  that  in  man 
the  visual  centre  is  situated  in  the  occipital  lobe,  rather  than 
in    the   angular   gyrus   or    elsewhere ;    and    the   evidence  goes 


Fig.  133. 


to  show  that  the  absolute  optical  centre  chiefly  occupies  the 
cortex  of  the  cuneus  and  of  the  superior  occipital  convolution, 
and  also,  especially  in  respect  of  the  color-sense,  the  posterior 
part  of  the  superior  and  inferior  occipito-temporal  convolutions. 
It  is  universally  recognized  that  the  nerve  fibres  from  the 
homonymous  half  of  each  retina,  e.  r/.,  the  temporal  half  of  the 
35 


410  DISEASES    OF    THE    EYE. 

right  and  the  median  half  of  the  left  retina,  pass  wholly  through 
the  corresponding  optic  tract — in  this  case  the  right  tract — to 
the  corresponding  cortical  centre  for  vision  (Figs.  134  and  135, 
yellow). 

A  case  pu-blished  by  Hun,*  in  which  the  left  lower  quadrant 
in  each  field  was  blind,  and  where  the  autopsy  showed  a  lesion 
(atrophy)  strictly  limited  to  the  lower  half  of  the  right  cuneus, 
renders  it  probable  that  there  is  in  man  a  correlation  between 
parts  of  the  retina  and  of  the  occipital  lobe,  as  Munk  had 
already  proved  to  be  the  case  in  dogs,  and  that  the  optic  fibres 
from  the  right  lower  quadrant  of  each  retina  terminate  in  the 
adjacent  part  of  the  right  superior  occipito-temporal  convolution, 
the  left  halves  of  the  retina  and  left  optic  centres  being,  of 
course,  similarly  correlated.  If  this  view  be  correct,  as  seems 
probable,  it  is  evident  that  altitudinal  hemianopsia  can  hardly 
occur  as  the  result  of  a  central  lesion,  as  nothing  short  of 
disease  confined  to  the  lower  half  of  each  cuneus  would  pro- 
duce it. 

It  is  also  probable  that  the  centres  for  the  three  visual 
perceptions  of  light,  form,  and  color  are  distinct  from  each 
other,  and  that  they  are  arranged,  as  it  were,  in  layers,  one  over 
the  other. 

It  is  now  generally  conceded  that  the  macula  lutea  is  specially 
represented  in.  the  cortical  centre ;  but  there  are  at  least  two 
very  distinct  views  as  to  the  arrangement  of  these  macular 
centres  and  as  to  the  course  of  the  macular  fibres.  These 
different  views  have  been  called  into  existence  by  the  desire,  to 
explain  the  fact  that  in  hemianopsia  the  line  of  demarcation 
sometimes  passes  through  the  fixation  point  in  the  field,  and 
sometimes  leaves  it  in  the  seeing  half  It  seems  to  me  that 
neither  of  these  theories  is  satisfactory,  and  I  regret  that  I 
cannot  oflfer  one  that  is  so. 

According  to  one  theory,  illustrated  by  Fig.  134,  the  whole  of 
the  macular  region — and  in  some  instances  even  more  than  this 

*  American  Journal  of  the  Medical  Sciences^  January,  1887. 


FIGA. 


L    F 


R  F. 


rmcc. 


EXPLANATION  OF  COLORED  FIGURE  (A)  ISL 


Fig  (A)  134 — Diagram  of  Cour??e  of  Optic  Fibres  wiih  the  centres  for 
the  Three  Visual  Perception?,  and  Relations  to  Fields  of  Vision  to  illus- 
trate one  theory  of  the  Macular  Supply ;  according  to  which,  each 
macula  lutea  is  innervated  from  each  hemisphere. 

R.F.,  Right  field  of  vision  ;  L.F.,  Left  field  of  vision  ;  E.E.,  Right  eye 
(retina) ,  L.  E  ,  Lef:  eye  (retina) ;  ML  and  Ml  ,  Macula  lutea ;  0.  X. 
and  O.N.,  Optic  nerves;  Ch.,  Chiasma  ;  Tr.  and  Tr.,  Optic  tracts; 
B.C  C.  and  L.C.C  .  Right  and  left  cortical  centres  ;  M  and  M.,  Macular 
fibres;  P.  and  P.,  Peripheral  fibres;  L  f,  c.  and  ?, /,  c,  Centres  for  the 
three  visual  perceptions — light  (/),  form  (/),  and  color  (c) — arranged  in 
layers. 

1.  Lesion  of  right  cortical  centre  =  lefc  homonymous  hemianopsia, 
with  the  line  of  demarcation  passing  round  the  fixation  point,  owing  to 
overlapping  of  supply  to  the  macula  from  the  opposite  hemisphere. 

2.  Lesion  of  the  right  tract  ^  lefc  homonymous  hemianopsia,  with  the 
line  of  demarcation  passing  round  the  fixation  point. 

3  Lesion  of  the  chiasma  =  temporal  hemianopsia,  with  the  line  of 
demarcation  passing  round  the  fixation  point. 

4.  Lesion  of  the  fisciculus  lateralis  only  to  the  right  eye,  causing  na?al 
hemianopsia  in  the  right  field. 


EXPLANATION  OF  COLORED  FIGURE  (B)  135, 


Fig.  (B)  135. — Diagram  of  Cour.se  of  Optic  Fibres,  wiih  the  centres 
for  the  Three  Visual  Perceptions,  and  Relations  to  Fields  of  Vision,  to 
illustrate  the  second  theory  of  the  Macular  Supply ;  according  to  which 
the  macula  is  supplied  on  the  same  plan  as  the  rest  of  the  retina,  i.  e., 
each  side  of  it  from  the  corresponding  side  of  the  brain. 

R.F.,  Right  field  of  vision;  L.F.,  Left  field  of  vision  ;  R.E.,  Right 
eye  (retina) ;  L  E.,  Lefc  eye  (retina) :  Ml.  and  ML,  Macula  lutea;  O.N. 
and  O.N.,  Optic  Nerves;  Ch.,  Chiasma;  Tr.  and  Tr.,  Optic  tracts; 
R.C.C.  and  L.C  C,  Right,  and  Itfc  cortical  centres  ;  M.  and  M.,  Macular 
fibres;  P.  and  P.,  Peripheral  fibres;  Z, /,  c,  and  Z, /,  c,  Centres  for  the 
three  visual  perceptions— light  (Z),  form  (/),  and  color  (c),— arranged  in 
layers. 

1.  Lesion  of  right  cortical  centre  =  left  homonymous  hemianopsia, 
the  line  of  demarcation  passing  round  the  left  side  of  the  fixation  point 
in  cases  of  embolism  and  thrombosis,  but  through  the  fixation  point  in 
cases  of  hemorrhage  (see  p   411). 

2.  Lesion  of  the  right  optic  tract  =  left  hemianopsia,  the  line  of 
demarcation  passing  through  the  fixation  point. 

3.  Lesion  of  the  chiasma  =  bitemporal  hemianopsia,  the  line  of 
demarcation  passing  through  the  fixation  point. 

4.  Lesion  involving  fasciculus  lateralis  only  to  right  eye,  causing  nasal 
hemianopsia  in  the  right  field. 

Diagrams  134  and  135  illustrate  the  fact  that,  as  regards  its  relation  to 
the  optic  tracts,  the  field  of  each  eye  is  divided  unequally,  and  not  in 
halves,  e.  g.,  the  right  tract  governs  about  one-third  of  the  field  of  the 
right  eye,  while  the  other  two-thirds  is  governed  by  the  left  optic  tract. 


FIG  B. 


L.F. 


R.¥. 


L.C.C.|^ 


f  IR.C.C. 
c 


AMBLYOPIA    AND    AMAUROSIS.  411 

— of  each  retina  being  innervated  from  each  hemisphere,  there  is 
an  overlapping,  as  it  is  called,  of  nervous  supply  to  these  retinal 
regions.  Consequently,  if  there  be  a  lesion  at  the  centre  for 
vision  in  one  occipital  lobe,  the  centre  for  vision  in  the  other 
occipital  lobe  being  sound,  the  functions  of  the  whole  of  each 
macula — or  even  of  more  than  this,  of  the  defective  side  of  each 
retina — will  be  preserved.  Cases  where,  occasionally,  in  cortical 
lesions,  the  line  of  demarcation  in  the  field  does  go  through  the 
fixation  point,  would  be  accounted  for,  under  this  theory,  by  an 
individual  variation  in  the  supply  of  the  maculae,  which,  in  these 
instances,  would  be  similar  to  that  of  the  remainder  of  the 
retinae. 

According  to  the  other  theory,  illustrated  by  Fig.  135,  the 
macular  region  of  the  retina  is  invariably  supplied  on  the  same 
plan  as  the  rest  of  the  retina,  i.  e.,  each  side  of  it  from  the 
corresponding  side  of  the  brain.  In  order,  then,  to  explain 
why  it  is  that  in  some  cortical  lesions  the  line  of  demarcation 
passes  through  the  fixation  point  in  the  field,  while  in  others  it 
deviates  toward  the  blind  side,  the  supporters  of  this  view  state 
that  the  cortical  centre  for  the  macular  region  is  more  richly 
supplied  with  blood-vessels  than  the  rest  of  the  visual  centre, 
as  is  the  macula  lutea  itself  in  relation  to  the  rest  of  the  retina. 
Hence,  when  the  lesion  is  an  embolism,  or  thrombosis,  of  the 
vessels  supplying  that  part  of  the  brain,  this  special  region,  by 
reason  of  abundant  anastomoses,  preserves  its  functions,  and 
then  fields  as  in  Fig.  132  are  produced.  But,  if  the  lesion  be 
a  hemorrhage,  the  macular  region  of  the  cortex  would  be  apt 
to  be  involved  in  the  lesion  with  the  rest  of  the  visual  centre, 
and  loss  of  function  in  the  corresponding  half  of  the  macula 
lutea,  with  the  line  of  demarcation  passing  through  the  fixation 
point,  results. 

But  any  such  theory,  to  be  satisfactory,  must  be  capable  of 
explaining  the  phenomenon  in  question,  not  only  when  the 
lesion  is  in  the  cortex,  but  also  where  the  hemianopsia  is 
caused  by  a  lesion  in  the  tract  or  chiasma.  Yet  an  examina- 
tion of  Fig.   134    will    show   that,  according   to   the   theory  it 


412  DISEASES    OF    THE    EYE. 

represeiit8,  in  lesions  of  the  tract  (2;  or  of  the  chiasma  (3) 
the  fixation  point  would  always  be  spared ;  and,  according 
to  the  theory  illustrated  by  Fig.  135,  a  lesion  either  at  the 
tract  or  at  the  chiasma  would  always  cause  the  dividing  line 
to  pass  through  the  fixation  point.  It  happens,  however,  that 
with  lesions  at  either  of  these  situations,  the  dividing  line 
sometimes  passes  through  the  fixation  point  and  sometimes  to 
one  side  of  it.  Consequently,  I  do  not  think  we  have  yet 
solved  the  problem  of  the  nervous  supply  of  the  macula  lutea. 

The  Localization  of  the  Lesion  in  Cases  of  hemianopsia  is  a 
subject  of  interest,  and,  in  view  of  the  advances  made  within 
recent  years  in  cerebral  surgery,  it  is  of  great  practical  im- 
portance. 

Temporal  Hemianopsia  (Fig.  133)  is  in  all  cases  due  to  a 
lesion  so  situated  at  the  chiasma  as  to  involve  the  fasciculus 
cruciatus  from  each  eye.  In  very  many  cases  of  temporal 
hemianopsia  the  other  side  of  the  field  is  somewhat  involved, 
owing  to  the  lesion  implicating  some  of  the  fibres  of  the  neigh- 
boring fasciculi  laterales. 

In  Altitudinal  Hemianopsia  the  lesion  must  also  be  at  the 
chiasma,  encroaching  on  it  from  above  or  below. 

In  Nasal  Hemianopsia,  too,  the  lesion  must  be  at  the 
chiasma,  and  must  be  so  situated  in  its  outer  angle  as  to 
involve  only  the  fasciculus  lateralis  of  the  affected  eye.  The 
occurrence  of  binocular  nasal  hemianopsia  is  evidently  almost 
impossible,  implying,  as  it  does,  symmetrical  lesion  of  the 
fasciculus  lateralis  of  each  tract. 

In  Homonymous  Hemianopsia — the  commonest  form  of  the 
symptom — localization  of  the  lesion  is  a  more  difficult  matter 
than  in  any  of  the  other  forms ;  for  here  the  disease  cannot  be 
situated  at  the  chiasma,  but  may  be  in  the  optic  tract,  or  in  the 
visual  centre,  or  anywhere  in  the  lengthened  course  of  the  fibres 
which  connect  these  two  parts. 

Can  we  distinguish  a  complete  and  absolute  hemianopsia,  due 
to  a  lesion  confined  to  the  occipital  lobe,  from  a  similar  defect  in 
the  field,  due  to  a  lesion  in  the  optic  radiations,  internal  capsule, 


AMBLYOPIA    AND    AMAUROSIS.  413 

pulvinar,  or  optic  tract?  We  may  conclude  that  the  hemianop- 
sia depends  upon  an  occipital  lesion  if  it  be  unaccompanied  by 
hemiplegia,  motor  aphasia,  or  paralysis  of  cerebral  nerves,  as  di- 
rect symptoms — as  might  occur  with  a  lesion  in  the  posterior 
limb  of  the  internal  capsule  on  the  left  side  (vide  infra) ;  but, 
be  it  remembered,  that  one  and  all  of  these  are  liable  to  accom- 
pany lesions  of  the  occipital  lobe  as  distant*  symptoms. 

Aphasia,  too,  occasionally  accompanies  right  cortical  hemi- 
anopsia (i.  e.,  due  to  a  lesion  in  the  left  occipital  lobe),  although 
it  is  not  easy  to  offer  a  satisfactory  explanation  of  the  fact. 

Cortical  hemianopsia  may  be  incomplete,  inasmuch  as  the 
homonymous  quadrant  only  of  each  field  may  be  wanting.  The 
explanation  of  this  has  been  given  when  speaking  (p.  410)  of  the 
correlation  of  the  visual  cortical  centres  to  parts  of  the  retina. 

Cortical  hemianopsia  may  be  a  distant  symptom.  Gowers 
has  observed  that,  at  the  onset  of  many  attacks  of  cerebral 
hemorrhage,  hemianopsia  is  present  as  a  distant  symptom  of  very 
fleeting  character,  so  fleeting,  indeed,  that  it  does  not  complicate 
attempts  at  localization.  Except  under  this  condition,  distant 
hemianopsia  seems  to  be  rare,  a  fact  which  enhances  the  localiz- 
ing value  of  the  symptom. 

So  much  for  absolute  hemianopsia.  But  the  lesion  may  be 
such  as  to  destroy  only  the  color  centre,  without  reaching  those 
for  form  and  light.  Eight  cases  of  hemiachromatopsia  are  on 
record. 


*I  suggest  the  term  "distant  symptom"  in  preference  to  those  in 
common  use — namely,  "indirect  symptom  "  and  "pressure  symptom." 
We  cannot  assume  that  these  symptoms  are  less  the  direct  result  of  the 
lesion  than  any  of  the  others  which  are  present ;  and,  in  many  instances, 
at  least,  it  is  certain  that  they  cannot  be  due  to  pressure.  In  short,  we  do 
not  yet  know  what  produces  these  symptoms, — they  may  be  caused  by 
inhibition,— we  only  know  that  they  are  the  result  of  interference  with 
functions  of  parts  of  the  brain  not  involved  in  the  lesion,  and  the  term 
"  distant  symptom  "  conveys  this  idea — although  perhaps  not  quite  gram- 
matically—without committing  us  to  any  theory.  The  corresponding 
German  term  is  "  Fernwirkung." 


414  J)ISEASi:S    OF    THE    EYE. 

Again,  the  form-sense  may  be  lost  in  the  half  field  along  with 
the  color-sense,  while  only  the  light-sense  is  retained.  Such 
cases  are  hardly  less  rare  than  the  loss  of  the  color-sense  alone. 
Furthermore,  cases  of  hemianopsia  are  on  record  in  which,  in 
part  of  the  defect,  both  the  color  and  form-senses  were  absent, 
but  the  light-sense  present,  while  in  the  remainder  of  the  defect 
all  three  visual  perceptions  were  lost. 

Hemianopsia  from  a  lesion  in  the  optic  radiations  will  often  be 
indistinguishable  from  the  same  symptom  due  to  a  cortical 
lesion.  The  defect  may  be  incomplete,  as  the  lesion  may  impli- 
cate only  some  of  the  radiating  fibres ;  or  it  may  be  complete  if 
they  are  all  involved.  Pronounced  distant  symptoms,  such  as 
hemiplegia,  hemiansesthesia,  ptosis,  and  so  on,  are  more  apt  to  be 
caused  by  a  lesion  here  than  in  the  cortex. 

A  lesion  in  the  posterior  third  of  the  posterior  limb  of  the 
internal  capsule — the  sensory  crossway — is  likely  to  produce 
complete  hemianopsia,  because  the  nerve  fibres  are  here  col- 
lected together  in  a  small  space.  Hemian^esthesia  will  be  pres- 
ent as  an  accompanying  direct  symptom ;  and  also,  sometimes, 
loss  of  the  other  special  senses  on  the  opposite  side  from  the 
lesion  ;  and,  should  the  disease  extend  forward  to  the  anterior 
part  of  the  posterior  limb,  hemiplegia  will  be  added  as  a  direct 
symptom.  Moreover,  if  the  lesion  be  on  the  left  side,  motor 
aphasia  may  be  present,  by  reason  of  the  proximity  of  the 
path  for  speech  on  its  way  to  the  cerebral  peduncle.  I  have 
already  spoken  of  the  combination  of  cortical  hemianopsia  with 
aphasia. 

There  are  a  few  cases  on  record  of  hemianopsia  caused  by  a 
lesion  in  the  pulvinar.  The  symptoms  in  such  cases  strongly 
simulate  those  present  in  many  cases  of  cortical  hemianopsia,  so 
that  a  diflferential  localization  as  regards  these  two  positions  may 
be  impossible.  The  hemianopsia  will  be  absolute,  and  probably 
complete  ;  but  lesions  just  in  this  situation  seem  to  be  very  rare. 

In  hemianopsia  due  to  a  lesion  of  the  optic  tract  the  defect  in 
the  field  is  usually  comj)lete. 

The  characteristic  sign  which  enables  us  to  localize  a  lesion  in 


AMBLYOPIA    AND    AMAUROSIS.  415 

the  optic  tract  from  one  elsewhere  causing  hemianopsia  is  the 
hemiopic  pupil.  Illumination  of  the  amaurotic  half  of  the 
retina  alone  produces  no  contraction  of  the  pupils,  or,  at  most — 
owing  to  dispersion  of  the  light  within  the  eye  and  consequent 
excitation  of  the  seeing  part  of  the  retina — a  very  sluggish  one  ; 
because  the  lesion  is  on  the  distal  side  of  the  corpora  quadri- 
gemina,  and,  consequently,  the  impulse  cannot  reach  Meynert's 
fibres  to  be  conducted  to  the  centre  for  the  third  nerve  (see  pp. 
273  and  283). 

It  must  be  stated  that  some  observers  deny  the  occurrence  of 
the  hemiopic  pupil.  But,  on  the  other  hand,  many  observers 
have  obtained  the  symptom.  A  great  obstacle  in  observing  it 
lies  in  the  difficulty  of  concentrating  the  light  on  the  blind  side 
of  the  retina,  without  allowing  it  to  fall  on  the  good  side.  It  is 
true  that  if  the  pupil-fibres  in  the  optic  nerve  run  as  Bechterew 
thinks  they  do  (p.  274),  the  hemiopic  pupil  could  not  occur. 

Lesions  of  the  optic  tract  are,  of  course,  apt  to  implicate  the 
crus  cerebri,  but  do  not  necessarily  do  so ;  and  then  we  would 
have  hemiplegia  of  the  opposite  side  of  the  body  associated  with 
the  hemianopsia.  Leber  has  pointed  out  that  atrophy  of  the 
optic  nerve  is  likely  to  make  its  appearance,  and  at  an  early 
stage  of  the  case,  in  lesions  of  the  tract. 

The  Forms  of  Diseased  Process  which  are  found  in  cases  of 
hemianopsia  are  :  Hemorrhage,  softening,  tumor,  abscess,  occa- 
sionally chronic  inflammatory  processes,  and,  sometimes — with 
the  lesion  in  the  occipital  lobe — trauma. 

The  Ophthalmoscopic  Appearances,  as  a  rule,  are  normal.  But, 
when  the  lesion  is  of  such  a  nature  as  to  produce  it,  optic  neuritis 
may  be  present.  With  temporal  hemianopsia  optic  atrophy  is 
not  uncommon. 

The  Prognosis  for  recovery  of  vision  in  the  defective  half  of 
the  field  depends,  of  course,  upon  the  nature  of  the  lesion  ;  but 
recovery  does  not  usually  take  place,  especially  in  the  most  com- 
mon class  of  cases — those,  namely,  which  are  due  to  cerebral 
apoplexy. 

Alexia  (a,priv.;  ?^i^i?,  speech),  or  Word-Blindness,  is  the  term 


416  DISEASES    OF    THE    EYE. 

given  by  Kussraaul  to  an  inability  to  understand  written  or 
printed  characters,  although  they,  and  other  small  objects,  can 
be  distinctly  seen.  The  patient  can  express  his  ideas  in  writing, 
or  write  from  dictation,  yet  cannot  understand  what  he  has  just 
written.  He  does  understand  the  meaning  of  spoken  words  and 
the  use  of  all  objects  around  him.  The  condition  has  been  occa- 
sionally complicated  with  hemianopsia.*  In  those  cases  where 
an  autopsy  was  obtained,  the  lesion  was  found  in  the  inferior 
parietal  lobule  of  the  left  hemisphere,  or  extending  from  it  into 
the  temporal  region  or  into  the  angular  gyrus  and  occipital 
lobule.t 

Dyslexia. — This  symptom  was  first  described  by  Berlin. j  In 
a  wide  sense,  it  belongs  to  the  aphasic  group.  It  consists  in  a 
want  of  power  on  the  patient's  part  to  read  more  than  a  very  few 
— four  or  five — words  consecutively,  either  aloud  or  to  himself. 
The  difficulty  is  not  caused  by  dimness  of  sight  nor  by  pain  in 
the  eye  or  head,  but  simply  by  an  unconquerable  feeling  of  dis- 
like or  disgust,  due  to  the  mental  effort.  After  a  few  words, 
which  can  be  well  understood,  have  been  read,  the  book  is  pushed 
away  and  the  head  drawn  backward  and  turned  aside;  and 
then,  in  a  moment  or  two,  the  patient  may  be  tempted  to  repeat 
the  effort,  but  with  the  same  result  after  a  very  few  words  have 
been  read.  The  symptom  comes  on  suddenly,  and  has  been 
usually  the  first  sign  of  the  presence  of  cerebral  disease. 
Although,  in  most  of  the  cases,  the  dyslexia  disappeared  in  the 
course  of  a  few  weeks,  either  permanently  or  to  recur  later  on, 
yet  other  symptoms  soon  followed  its  first  onset,  such  as  head- 
ache, giddiness,  aphasia,  hemianopsia,  paralysis  of  the  tongue, 
hemiansesthesia,  hemiplegia,  twitching  of  the  facial  muscles,  etc. 

^  Charcot  in  Gaz.  des.  Hop.,  Mai,  1883. 

t  Ferrier,  "Functions  of  the  Brain,"  2d  ed.,  p.  454;  Allen  Starr, 
Brain,  July,  1889,  p.  82. 

X  Archiv  fur  Psychiatrie  und  N erven  Krankheiten,  vol.  xv,  p.  276,  and 
in  his  Monograph,  "  Eine besondere  Art.  der  Wortblindheit  (Dyslexic)" 
(Wiesbaden,  1887). 


AMBLYOPIA    A^'D    AMAUKOiSlS.  417 

Seven  or  eight  cases  are  on  record,  and  all  have  ended  fatally. 
The  lesion  was  situated,  in  all  but  one  of  those  cases  where  an 
autopsy  was  obtained,  in  the  neighborhood  of  Broca's  lobe.  In 
one  case  the  left  hemisphere  was  normal,  while  the  right  hemi- 
sphere was  extensively  diseased. 

Soul-Blindness,  Psychical-Blindness,  or  Mind-Blindness  is  a 
symptom  first  observed  by  Munk  "^  in  his  experiments  upon 
animals.  It  consists  in  the  loss  of  power  of  recognizing  objects, 
while  the  power  of  seeing  them  continues.  A  whip  is  seen  by 
the  animal,  but  inspires  no  terror;  attempting  morsel  is  seen, 
but  excites  no  desire.  The  symptom  was  caused  by  destruction 
of  a  region  situated  chiefly  in  the  posterior  division  of  the  second 
external  convolution  of  the  dog's  brain.  Ferrier  seems t  dis- 
inclined to  accept  Munk's  experiments.  The  symptom,  however, 
has  been  observed  in  man  under  certain  diseased  states,  e.  g.,  after 
apoplectic  seizures  and  in  progressive  paralysis.  Some  authors 
localize  the  centre  for  visual  memory  in  the  angular  gyrus,  while 
others  take  it  for  the  whole  of  the  occipital  lobe,  except  the 
cuneus  and  its  neighborhood. 

Congenital  Amblyopia. — This  condition  is  not  very  uncommon. 
Ophthalmologists,  in  the  course  of  their  practice,  come  across 
people  in  whom  the  vision  of  both  eyes  is  below  the  normal 
standard,  even  with  perfect  correction  of  any  error  in  refraction, 
and  who  declare  that  they  never  have  seen  better  and  that  their 
sight  is  not  getting  worse.  Still  more  common  is  a  congenital 
amblyopia  in  one  eye.  As  a  rule,  the  field  of  vision  and  the 
color- vision  are  normal,  but  cases  are  seen  in  which  there  is 
contraction  of  the  field  with  defective  color-sight. 

The  Ophthalmoscopic  Appearances  are  normal. 

Reflex  Amblyopia  is  said  to  have  been  observed,  and  chiefly 
in  connection  with  irritation  of  the  fifth  pair,  especially  its 
dental   branches;  but  I  have  not  seen  these  cases  and  I  am 

*  "  Zur  Physiologie  der  Grosshirnrinde,"  Archiv  f.  Anat.  und  Phys- 
iol.,, V  and  vi,  pp.  162  and  547. 

t  "The  Functions  of  the  Brain,"  2d  ed.,  p.  298. 


418  DISEASES    OF    THE    EYE. 

rather  skeptical  as  to  their  occurrence.  Carious  molar  teeth  are 
reputed  to  be  its  frequent  cause,  usually  with  severe  toothache, 
but  sometimes  without  it.  The  defect  of  vision  may  be  confined 
to  the  side  of  the  carious  tooth,  and  is  nearly  always  most 
marked  on  that  side.  It  is  said  that  it  may  be  of  extreme 
degree,  vision  being  reduced  even  to  the  merest  perception  of 
light. 

More  generally  recognized  than  amblyopia,  as  the  result  of 
toothache,  are:  Hypersesthesia  of  the  retina,  photophobia,  sub- 
jective sensations  of  light,  and  diminution  in  the  amplitude  of 
accommodation. 

All  these  symptoms,  even  amblyopia  of  the  severest  type, 
disappear  when  the  dental  affection  is  relieved. 

Many  cases  are  on  record  in  which  wounds  of  the  supraorbital 
nerve  were  looked  on  as  the  cause  of  amblyopia  or  of  amaurosis, 
but  it  is  by  no  means  certain  that  an  ophthalmoscopic  examina- 
tion would  not  have  afforded  another  explanation  in  many  of 
these  cases.  Yet,  even  nowadays,  many  hold  that  wounds  of  the 
supraorbital  region  can  produce  amblyopia,  as  cases  are  said  to 
have  been  cured  by  division  of  the  nerve  involved  in  a  cicatrix 
that  was  tender  on  pressure. 

Sympathetic  Irritation  (p.  261)  is  to  be  included  under  this 
heading.  It  is  seen  in  the  sound  eye  in  some  cases  of  cyclitis,  and 
must  not  be  confounded  with  sympathetic  ophthalmitis,  which 
comes  about  in  quite  a  difl^erent  way.  Its  symptoms  are: 
Diminution  of  the  amplitude  of  accommodation,  asthenopia,  hy- 
persesthesia  of  the  retina,  lachrymation,  and  subjective  appear- 
ances of  light. 

Removal  of  the  first  eye,  if  otherwise  indicated,  always  re- 
lieves sympathetic  irritation  ;  but  where  this  is  not  admissible 
the  dark  room,  atropine,  dry  cupping  at  the  temple,  with  bro- 
mide of  potassium  internally,  may  be  employed. 

The  Ophthalmoscopic  Appearances  in  reflex  amblyopia  are  nor- 
mal. 

Hysterical  Amblyopia. — In  hysterical  individuals  amblyopia 
is  sometimes  seen,  either  as  the  only  symptom  or  in  combination 


AMBLYOPIA    AND    AMAUROSIS.  419 

with  Others.  It  takes  various  forms,  e.  g.,  complete  blindness, 
even  to  loss  of  perception  of  light;  defective  central  vision,  with 
concentric  contraction  of  the  field,  or  with  segmental  peripheral 
defects  in  the  latter,  or  as  central  scotoma.  The  color  vision  is 
often  affected. 

The  Ophthalmoscopic  Appearances  are  normal  and  the  Prog- 
nosis good. 

Treatment  must  be  directed  to  the  general  system. 

Nyctalopia  (Xight-Blindness). — This  is  a  well-recognized 
symptom  of  the  disease  known  as  Retinitis  Pigmentosa  (p.  373). 
I  have  recorded"^  an  instance  of  congenital  night-blindness  in 
five  members  of  a  family  of  ten  children,  without  ophthalmo- 
scopic signs,  and  Richter,  quoted  by  Lawrence,  observed  a  simi- 
lar instance.  But  the  condition  of  which  I  have  here  to  speak 
is  Acute,  or  Idiopathic,  Night-Blindness. 

The  patients  can  see  well  in  good  daylight,  but  of  a  very  dull 
day,  or  in  the  dusk  of  evening,  or  by  indifferent  artificial  light, 
their  vision  sinks  very  much  more  than  that  of  persons  with 
normal  eyes.  They  are  then  unable  to  see  small  objects,  which 
are  quite  plain  to  other  people,  and,  in  a  still  worse  light,  they 
fail  even  to  recognize  large  objects  visible  to  every  one  else. 
This  peculiar  visual  defect  is  due  to  imperfect  adaptation  power 
of  the  retina,  and  not  to  defective  light-sense,  as  is  sometimes 
stated. 

Conjunctivitis  and  xerosis  of  the  conjunctiva  are  often  present 
in  acute  nyctalopia  (p.  115).  Some  observers  have  found  mi- 
crococci and  bacilli  in  the  conjunctiva  in  these  cases,  and  have 
regarded  these  organisms  as  the  cause  of  the  conjunctival  affec- 
tion. It  seems  now  more  probable  that  they  are  merely  second- 
ary to  the  xerosis. 

The  connection  between  nyctalopia  and  xerosis  conjunctiva- 
remains  to  be  explained,  but  it  is  likely  that  they  are  both  re- 
sults of  the  one  cause. 

Acute    nyctalopia    is    often    the    result    of    long  continued 


*  Irish  Hospital  Gazette,  March  15,  181 


420  DISEASES    OF    THE    EYE. 

dazzling  by  very  bright  sunlight  or  of  lengthened  exposure  to 
bright  firelight  (e.  (jr.,  in  foundries),  and  it  is  probable  that  in 
many,  if  not  in  most,  instances  of  this  affection  defective  nutri- 
tion of  the  system  plays  the  chief  role  in  rendering  the  patients 
liable  to  it.  Thus,  in  scorbutus,  acute  nyctalopia  has  been  fre- 
quently seen  when  the  patients  have  been  exposed  to  strong 
glares  of  sunlight. 

Treatment  consists  in  protection  from  light, — in  short,  in  com- 
plete darkness  for  a  time, — and  then  gradual  return  to  ord'nary 
daylight ;  while  the  system  is  to  be  strengthened  by  careful  die- 
tary and  suitable  tonic  medicines. 

Uraemic  Amblyopia. — This  is  most  commonly  seen  in  connec- 
tion with  the  nephritis  of  pregnancy  and  scarlatina,  but  may 
occur  in  any  case  of  ur?emic  poisoning.  The  blindness  is  usu- 
ally absolute,  and  may  come  on  suddenly,  or  with  a  short  pre- 
vious stage  of  dimness  of  vision. 

The  Ophthalmosco2:>ic  Appearances  are  negative. 

Treatment  can  only  be  directed  to  the  general  condition. 

The  Pror/nosis  for  vision  is  good,  as  it  always  recovers  if  the 
patient's  life  be  spared. 

Snow-Blindness. — Exposure  of  the  unprotected  eyes  for  a 
length  of  time  to  the  glare  from  an  extensive  surface  of  snow 
produces  dimness  of  sight,  which  may  amount  to  almost  com- 
plete blindness,  but  which  usually  passes  off  again  as  soon  as 
regions  free  of  snow  are  reached.  One  or  two  instances  have 
been  recorded  in  which  the  affection  continued  some  days 
after  the  exposure  and  then  underwent  recovery. 

Pretended  Amaurosis. — Malingerers  rarely  pretend  total 
blindness  of  both  eyes,  and  such  cases  can  often  only  be 
detected  by  constant  observation  of  their  actions. 

Presence  of  pupillary  reflex  is  no  proof  that  the  patient  sees, 
for  this  would  be  quite  compatible  with  a  cortical  lesion  causing 
total  loss  of  sight  (p.  284). 

The  crossed  diplopia  test  {vide  infra)  may  be  employed  in 
these  cases,  as,  if  both  eyes  see,  the  one  with  the  prism  will 
rotate  inward  for  the  sake  of  single  vision,  while  if  both  eyes 


AMBLYOriA    AND    AMAUROSIS.  4"21 

be  blinr ,  of  course  no  such  motion  will  take  place.  Again,  if 
the  mal  ngerer's  own  hand  be  placed  in  various  positions,  and  he 
be  asked  to  look  at  it,  he  will,  in  all  probability,  look  in  some 
other  direction ;  whereas,  a  truly  blind  man  usually  makes  a 
fair  attempt  at  directing  his  eyes  toward  his  own  hand. 

Pretended  monocular  amaurosis  can  generally  be  detected  by 
The  Diplopia  Test.  If  the  malingerer  be  made  to  look,  with 
both  eyes  open,  at  a  lighted  candle  placed  some  feet  off,  while  a 
prism  with  its  base  downward  is  held  before  the  admittedly 
good  eye,  he  will  say  he  sees  two  images  of  the  light,  one  over 
the  other.  Were  he  blind  of  one  eye,  he  would  not  see  two 
images. 

Another  method — The  Crossed  Diplopia  Test — consists  in 
holding  a  prism  of  some  10^  or  12°  with  its  base  outward  before 
the  pretended  blind  eye  ;  when,  if  he  sees,  it  will  make  a  rotation 
inward  for  the  sake  of  single  vision,  an  effort  which  a  blind  eye 
would  not  make. 

Alfred  Graefe's  Method. — In  this  test  the  pretended  blind  eye 
is  covered  with  the  surgeon's  hand  from  behind  the  patient, 
while  with  the  other  hand  a  prism  (about  10°)  is  held  base 
down  before  the  good  eye,  so  that  its  edge  may  pass  horizontally 
across  the  centre  of  the  pupil.  Monocular  double  vision  results, 
as  the  rays  pass  through  the  upper  part  of  the  pupil  normally, 
while  through  the  lower  part  of  it  they  are  refracted  downward 
by  the  prism.  The  double  images  stand  over  each  other.  If 
now  the  hand  which  excludes  the  pretended  blind  eye  be  rap- 
idly removed,  while  at  the  same  moment  the  prism  is  moved 
upward,  so  that  the  entire  pupil  is  covered  by  it,  a  malingerer 
will  still  see  double  images  standing  one  over  the  other,  for  now 
the  diplopia  must  be  binocular. 

Harlan's  Test"^  consists  in  placing  a  trial  frame  on  the  patient's 
nose  with  a  very  high  -j-  lens — say  -{-  14  D — opposite  the  good 
eye,  by  which  means  it  is  excluded  from  distant  vision,  and  a 
plane  glass — or  a  0.25  D  convex  or  concave  lens,  which,  of  course, 


Trans.  Amer.  Ophthal.  Soc,  vol.  iii,  p.  400. 


422  DISEASES    OF    THE    EYE. 

would  not  materially  iuterfere  with  its  distant  vision — opposite  the 
pretended  blind  eye.  The  patient  then,  believing  there  is  much 
the  same  kind  of  glass  before  each  eye,  will  read  the  test-types, 
and  if  it  be  now  desired  to  expose  the  deception,  the  pretended 
blind  eye  is  excluded  from  sight,  and  the  malingerer  will  then  be 
unable  to  read  the  test-types. 

Snellen's  Colored  Types  may  also  be  used  for  this  purpose. 
These  types  are  printed  in  green  and  red.  If  a  person  be  really 
blind  of  one  eye  he  will,  of  course,  see  both  the  green  and  the 
red  letters  with  the  good  eye.  But  if  a  green  glass  be  held  be- 
fore the  good  eye  the  rays  from  the  red  letters  will  be  excluded 
and  he  will  now  only  see  the  green  letters,  or  with  a  red  glass 
the  red  letters  alone  will  be  seen.  A  malingerer  may  be  detected 
by  holding  before  his  admittedly  good  eye  a  green  glass,  and  if 
he  now  still  see  the  red  letters  it  must  be  that  he  does  so  with  the 
so-called  blind  eye. 

It  is  well  to  have  this  variety  of  tests  in  order  that  they  may 
be  used  to  corroborate  each  other. 

Erythropsia  (Jf>o0f>6i,  red — Red  Vision).  A  large  number  of 
cases  of  this  remarkable  affection  are  on  record  ;  indeed,  it  will 
have  come  under  the  notice  of  nearly  every  ophthalmic  surgeon 
of  any  experience.  Two-thirds  of  the  cases  have  been  subjects 
of  successful  cataract  operations,  whilst  the  remainder  have  pos- 
sessed normal  eyes.  In  some  cases  the  red  vision  remains  only  a 
few  minutes  and  does  not  again  return  ;  whilst  in  others  it  ap- 
pears every  day  for  a  short  time,  for  weeks  or  months ;  and, 
again,  in  others  it  continues  for  several  days  and  then  disappears 
for  good,  or  recurs  at  intervals.  In  the  aphakic  cases  it  does 
not  usually  appear  for  weeks  or  months  after  the  removal  of  the 
cataract,  and,  in  one  case,  the  interval  was  two  years.  During 
the  attacks  the  patients  see  all  objects  of  a  deep  red  color,  and 
occasionally  of  a  purple  or  violet  hue.  In  no  instance  is  the 
acuteness  of  vision  affected,  either  during  or  after  the  attacks. 

A  satisfactory  explanation  for  the  affection  has  not  yet  been 
offered.  It  seems  probable  that  it  is  due  to  over-excication  of 
the  visual  nervous  apparatus — some  believe  of  the  visual  centre, 


AMBLYOPIA    ANT)    AMAUROSIS.  428 

Others  of  the  retina — set  agoing  by  exposure  of  the  retiua  to 
strong  light,  along  with  other  favoring  circumstances,  especially- 
general  over-excitement  of  the  body  or  mind.  More  than  this 
cannot  at  present  be  said.  Why  aphakic  eyes  should  be  so  much 
more  liable  to  erythropsia  than  eyes  which  possess  their  crystal- 
line lenses  is  an  enigma. 

Treatment  seems  to  have  but  little  effect.  Protection  of  the 
eyes  from  light  has  not  been  of  use.  Bromide  of  potassium  in- 
ternally seems  to  have  done  some  good  in  those  cases  where  it 
was  tried. 


CHAPTER  XVIII. 

THE  MOTIONS  OF  THE  EYEBALLS  AND 
THEIR  DERANGEMENTS. 

The  eyeball  moves  round  a  point  on  its  autero-posterior  axis 
situated  (in  the  emmetropic  eye)  14  millimetres  behind  the  cor- 
nea and  10  millimetres  in  front  of  the  posterior  surface  of  the 
sclerotic.  Its  motions  are  effected  by  means  of  the  six  orbital 
muscles,  arranged  in  three  pairs,  each  pair  consisting  of  two  an- 
tagonistic muscles  ;  thus,  the  rectus  internus  and  rectus  externus 
are  antagonistic,  the  former  rotating  the  eye  inward  and  the 
latter  rotating  it  outward.  The  two  remaining  pairs  are  the 
recti  superior  and  inferior,  and  the  obliqui  superior  and 
inferior. 

The  Primary  Position  of  the  Eyeball  is  that  one  in  w^hich,  the 
head  being  held  erect,  the  gaze  is  directed  straight  forward  in  the 
horizontal  plane.  This  is  the  starting-point  from  which  the 
actions  of  the  muscles  are  considered. 

The  Rectus  Externus  and  Pectus  Internus,  lying  from  their 
origin  to  their  insertion  in  a  plane  which  corresponds  with  that 
of  the  horizontal  plane  of  the  eyeball,  move  the  latter  on  its 
perpendicular  axis  directly  inward  and  outward,  and  have  no 
other  action. 

The  plane  of  The  Pectus  Suj^erior  and  Pectus  Inferior  does  not 
quite  correspond  with  the  vertical  plane  of  the  eyeball,  and  con- 
sequently the  axis  on  which  they  rotate  the  globe  is  not  its  hori- 
zontal axis,  but  one  which,  passing  from  within  and  before, 
backward  and  outward,  forms  with  the  antero-posterior  axis  an 
angle  of  70°  (Fig.  137).  While,  then,  their  action  is  mainly  to 
rotate  the  eyeball  upward  and  downward,  these  muscles  rotate 

424 


THE    ORBITAL    MUSCLES. 


425 


Fig.  1 


it  also  somewhat  inward.  Moreover,  the  superior  rectus  giving 
to  the  vertical  meridian  of  the  cor- 
nea an  inward  inclination  or  inward 
wheel-motion^  of  the  eye  {vide 
infra),  while  the  inferior  rectus 
gives  this  meridian  an  outward  in- 
clination or  outward  wheel-motion 
of  the  eye,  the  power  of  these  mus- 
cles over  the  upward  and  downward 
motions  is  greatest  when  the  eye  is 
turned  out,  for  then  their  axis  of 
rotation  coincides  most  closely  with 
the  horizontal  axis  of  the  globe  ; 
and  their  influence  over  the  wheel- 
motion  is  greatest  when  the  eye  is 
turned  in,  for  then  their  axis  coin- 
cides most  closely  with  the  antero-posterior  axis  of  the  globe. 

The  plane  of  The  Oblique  Muscles 
of  the  eyeball  also  approaches  the 
vertical  plane  of  the  eyeball,  the 
axis  upon  which  they  rotate  the  lat- 
ter passing  from  within  and  behind, 
forward  and  outward,  and  mak- 
ing with  the  antero-posterior  axis 
an  angle  of  35°  (Fig.  138).  The 
principal  action,  accordingly,  of 
the  oblique  muscles  is  to  incline  the 
vertical  meridian  of  the  cornea ; 
the  sup.  oblique  inclines  it  inward 
(wheel-motion  inward),  the  inf.  ob- 
lique inclines  it  outward  (wheel- 
motion  outward).  In  addition  to 
^  this  action  the  oblique  muscles, 
"^^1%^        '/  respectively,   rotate    the    eyeball 

*  In  speaking  of  the  inclination  of  the  vertical  meridian  of  the  cornea, 
it  is  the  upper  extremity  of  this  meridian  which  is  meant. 
36 


426 


DISKASES    OF    THK    EYE. 


downward  and  outward  (sup.  oblique),  and  upward  and  outward 
(inf.  oblique).  It  is  evident  that  the  power  of  these  muscles 
over  the  upward  and  downward  motions  of  the  eyeball  is  great- 
est, if  the  eye  be  turned  in,  and  that  their  power  over  the 
wheel-motion  is  greatest  when  the  eye  is  turned  out. 

To  sum  up,  then,  the  superior  oblique  and  rectus  produce 
wheel-motion  inward,  while  the  inferior  oblique  and  rectus  pro- 
duce w^heel-motion  outward.  The  action  of  the  obliques  on  the 
wheel-motion  is  greatest  when  the  eye  is  rotated  outward,  and  of 
the  recti  when  the  eye  is  rotated  inward. 

In  considering  the  motions  of  the  eyeballs,  we  have  to  think 
of  the  motions  of  one  eyeball  as  associated  with  those  of  its  fel- 
low ;  e.  g.,  the  action  of  the  internal  rectus  of  the  left  eye  is  asso- 
ciated with  the  action  of  the  external  rectus  of  the  right  eye,  in 
rotation  of  both  eyeballs  to  the  right. 

The  vertical  meridian  of  the  eyes  becomes  inclined  to  the  right  or 
left  in  different  positions  of  the  globe,  as  has  been  experiment- 
ally proved  by  Donders. 

1.   In  the  primary  position,  as  also  when  the  eyes  are  turned  di- 
rectly inward,  outward, 
^^^-  ^'^^-  upward,   or   downward, 

the  vertical  meridians 
(a,  h,  Figs.  138-143) 
maintain  their  vertical 
direction  (Fig.  139). 

2.  When  the  eyes  are 
turned  to  the  left,  and 
iipivard,  the  vertical 
meridian  of  each  eye  is  inclined  at  the  same  angle  to  the  left 
(Fig.  140).     Wheel-motion  to  the  left. 

3.  When  the  eyes  are  turned  to  the  left,  and  downward,  the 
vertical  meridian  of  each  eye  is  inclined  to  the  right  at  the  same 
angle  (Fig.  141).     Wheel-motion  to  the  right. 

4.  When  the  eyes  are  turned  to  the  rirjht,  and  upward,  the 
vertical  meridian  of  each  eye  is  inclined  at  the  same  angle  to 
the  right.     Wheel-motion  to  the  right  (Fig.  142). 


THE    ORBITAL    MUSCLES. 


427 


5.  When  the  eyes  are  turned  to  the  right,  and  downward^ 
the  vertical  meridian  of 
each  eye  is  inclined  at 
the  same  angle  to  the 
left.  Wheel-motion  to 
the  left  (Fig.  143). 

We  shall  now  con- 
sider which  muscles  are 
called  into  action  when 

an  individual  requires  to  place  his  eye  in  the  several  principal 
Fig    in  positions. 

1.  In  the  Primary 
Position  all  the  muscles 
are  at  rest. 

2.  Motion  of  the  eye- 
ball directly  outward  is 
effected  by  the  external 

"  rectus  alone,  and  motion 

directly  inward  by  the  internal  rectus  alone. 

3.  Motion  of  the  eye- 
ball directly  upward  and 
directly  downward  is 
effected  chiefly  by  aid 
of  the  sup.  and  inf. 
recti.  But  these  mus- 
cles, acting  alone,  rotate 
the  eyeball  slightly  in- 
ward, and  give  a  certain  inclination   to  the  vertical  meridian, 

which,  in  this  position, 
^^^-  1^^-  should  be  upright.  Con- 

sequently, in  rotation 
of  the  globe  directly 
upward,  the  inf.  ob- 
lique, which  rotates  the 
eye  slightly  outward  (as 
well  as  upward),  and 
inclines  the  vertical  meridian  outward,  must  be  associated  with 


Fig.   142. 


428  DISEASES    OF    THE    EYE. 

the  sup.  rectus  in  order  to  counteract  in  these  particulars  the 
tendency  of  its  action.  In  rotation  of  the  eyeball  directly 
downward,  the  inf  rectus  must  be  associated  with  the  sup. 
oblique,  which  acts  antagonistically  to  this  rectus  in  respect  of 
rotation  inward,  and  of  outward  wheel-motion. 

4.  Kotation  upward  and  outivard  is  chiefly  effected  by  aid  of 
the  rectus  superior  and  rectus  externus.  But  the  latter  muscle 
has  no  influence  over  the  wheel-motion,  while  the  former  pro- 
duces wheel-motion  inward.  Yet,  the  inclination  of  the  vertical 
meridian  is  outward  in  this  position,  and,  therefore,  a  third 
muscle,  which  will  supply  this  inclination  in  a  high  degree,  is 
required — namely,  the  inferior  oblique,  whose  power  over  the 
wheel-motion  of  the  eyeball  is  greatest  when  the  latter  is  in  this 
position. 

5.  Rotation  doivnward  and  outivard  is  chiefly  effected  by  the 
rectus  inf  and  rectus  ext.  Inasmuch,  however,  as  the  former 
inclines  the  vertical  meridian  outward,  while  the  latter  has  no 
influence  over  it  at  all,  a  third  force  is  required,  which  will  bring 
about  the  required  inward  wheel-motion — namely,  the  sup. 
oblique,  whose  influence  in  this  respect  is  most  powerful  when 
the  eye  is  in  this  position. 

6.  Rotation  upward  and  inward  is  chiefly  brought  about  by 
the  rectus  superior  and  rectus  internus.  But  the  effect  of  the 
former  upon  the  inward  wheel-motion  of  the  eye  would  be  so 
great  as  to  interfere  with  parallelism  of  the  vertical  meridians  of 
the  two  eyes,  that  of  the  other  eye  not  being  inclined  outward  in 
a  corresponding  degree.  A  third  force,  therefore,  is  required, 
which  will,  to  a  certain  extent,  counteract  the  influence  of  the 
sup.  rectus  in  this  respect,  and  this  is  the  inf.  oblique,  which,  in 
this  position  of  the  eyeball,  has  but  slight  power  over  its  wheel- 
motion. 

7.  Rotation  downward  and  inward  is  chiefly  the  result  of  con- 
traction of  the  rectus  inf  and  rectus  int.  The  power  of  the 
former  over  the  outward  inclination  of  the  vertical  meridian 
would,  in  a  similar  way,  be  too  great,  and  must  be  similarly 
corrected  by  the  action  of  the  superior  oblique. 


the  orbital  muscles.  429 

Paralyses  of  the  Orbital  Muscles. 

Loss  of  power  of  one  or  more  of  the  muscles  of  the  eyeball 
is,  of  course,  always  to  be  regarded  as  a  symptom,  not  as  itself  a 
disease. 

It  may  be  due  to  lesions  in  several  different  situations,  namely  : 
1.  Lesions  situated  in  the  orbit.  2.  Peripheral,  also  called  basic, 
lesions — lesions  situated  at  the  sphenoidal  fissure,  and  those  at 
the  base  of  the  skull,  between  that  point  and  the  pons.  3.  Pon- 
tine or  nuclear  lesions — lesions  in  the  substance  of  the  pons  and 
those  which  only  attack  the  nuclei  of  the  nerves  in  the  aqueduct 
of  Sylvius  and  floor  of  the  fourth  ventricle.  4.  Cerebral  lesions 
— lesions  above  the  nuclei  in  the  internal  capsule,  corona  radiata, 
or  cortex.  These  four  classes  differ  considerably  in  their  clinical 
aspect,  in  their  pathological  causes,  and  in  their  significance  for 
the  well-being  of  the  patient. 

The  first  class — loss  of  power  due  to  orbital  lesions — will  be 
referred  to  in  the  chapter  on  Diseases  of  the  Orbit. 

The  second  class — those  due  to  peripheral  lesions — provides 
by  far  the  largest  number  of  cases  of  paralyses  of  the  orbital 
muscles.     Let  us  now  consider  the — 

General  Symptoms  of  this  class.  They  include  symptoms  to 
be  found  in  each  of  the  other  classes.  1.  Diplopia.  The  affected 
eye  being  deviated  from  its  correct  position  and  being  more  or 
less  incapable  of  associated  motions  with  the  other  eye,  the  image 
of  the  object  looked  at  is  not  formed  on  identical  spots  of  the 
retina  in  each  eye,  and  hence  the  object  seems  doubled.  2.  In- 
distinct vision.  If  the  paralysis  be  but  slight,  actual  diplopia 
may  not  be  present,  but  the  double  images  overlapping  each 
other  will  cause  dimness  or  confusion  of  sight.  3.  Giddiness, 
due  partly  to  the  diplopia  and  partly  to  faulty  projection  of  the 
object.  4.  Some  patients  turn  the  head  toward  the  side  of  the 
paralyzed  muscle  in  order  to  diminish  or  eliminate  the  diplopia ; 
e.  ^  ,  if  the  left  ext.  rectus  were  paralyzed  the  head  would  be 
turned  toward  the  left;  if  it  were  the  left  int.  rectus  the  head 
would  be  turned  toward  the  right.     By  this  manoeuvre  the  loss 


430  DISEASES    OF    THE    EYE. 

of  the  action  of  the  affected  muscles  is  less  felt  for  objects  which 
lie  straight  in  the  patient's  path  while  he  walks  about,  as  it  in- 
volves a  rotation  of  the  eye  toward  the  side  of  the  healthy 
antagonist,  in  which  region  of  the  binocular  field  the  diplopia  is 
reduced  to  the  minimum.  Some  patients  close  one  eye  to  procure 
single  vision.  5.  In  peripheral  paralysis  it  is  most  common  to 
find  only  the  muscle  or  muscles  supplied  by  some  one  nerve — 
the  third,  fourth,  or  sixth — affected,  although,  of  course,  excep- 
tions to  this  are  not  rare,  especially  where  a  neoplasm  forms  at 
the  base  of  the  skull. 

In  studying  a  case  of  paralysis  of  an  orbital  muscle,  the 
following  General  Principles  should  be  borne  in  mind  :  1.  The 
defective  mobility  and  the  diplopia  increase  toward  the  side  of 
the  affected  muscle,  e.  g.,  toward  the  left  if  the  left  external 
rectus  be  paralyzed,  toward  the  right  if  the  left  internal  rectus 
be  paralyzed.  2.  The  secondary  deviation  (i.  e.,  the  deviation 
of  the  sound  eye  while  the  affected  eye  fixes)  is  greater  than  the 
primary  deviation  {i.  e.,  the  deviation  of  the  affected  eye  while 
the  sound  eye  fixes).  Because  the  muscle  in  the  sound  eye, 
which  is  associated  in  its  action  with  the  paralyzed  muscle  in  the 
affected  eye  (e  g.,  the  rect.  int.  with  the  rect.  ext.),  must  receive 
a  nervous  impulse  of  equal  intensity  to  that  sent  to  the  weak 
muscle,  and,  as  the  latter  requires  a  considerable  impulse  to  ex- 
cite its  action,  its  associate  will  be  over-excited.  Let  us  suppose 
the  left  external  rectus  to  be  paralyzed,  and  that,  shading  the 
right  eye  with  a  hand,  we  direct  the  patient  to  fix  with  his  left 
eye  an  object  held  somewhat  to  his  left-hand  side ;  we  may  notice 
on  removing  the  shading  hand  that  the  right  eye  has  been 
rotated  inward  to  an  extent  far  exceeding  that  of  the  primary 
deviation  of  the  left  eye,  and  has  now  to  make  an  outward  motion 
in  order  again  to  fix  the  object.  3.  The  image  formed  on  the 
retina  of  the  affected  eye  is  projected  (seems  to  lie)  in  the  direc- 
tion of  the  paralyzed  muscle;  e.g.,  if  the  left  ext.  rect.  be 
paralyzed  the  image  of  that  eye  will  be  formed  to  the  inside  (at 
/?,  Fig.  144)  of  the  macula  lutea  (?n'),  and  will,  therefore,  seem 
to  lie  to  the  left  (at  h')  of  the  image  belonging  to  the  right  eye. 


THE    ORBITAL    MUSCLES. 


431 


Where  the  image  of  the  affected  eye  lies  to  the  corresponding 
side,  as  in  this  instance,  the  diplopia  is  termed  homonymous, 
and  such  double  vision  always  indicates  convergence  of  the 
visual  lines. 

But,  suppose  the  internal  rectus  of  the  left  eye  to  be  para- 
lyzed, the  image  on  the  retina  of  that  eye  falls  then  to  the 
outside  of  its  macula  lutea,  and  must,  therefore,  be  projected 
to  the  right  of  the  true  position  of  the  object ;  this  is  crossed 
diplopia,  and  attends  divergence  of  the  visual  lines. 

Fig.  144. 


Paralysis  of  the  External  Rectus  of  the  Left  Eye.— If  this 
be  complete,  or  considerable,  it  is  easy  of  diagnosis,  as  marked 
loss  of  power  of  motion  of  the  eyeball  outward  is  present,  and 
the  patient  complains  of  double  vision.  He  keeps  his  head 
turned  to  the  left,  in  order  to  diminish  the  influence  of  the 
paralyzed  muscle  as  much  as  possible. 

If,  however,  the  paralysis  be  but  slight,  the  patient  may  not 
complain  decidedly  of  diplopia,  but  only  of  indistinctness  or 
confusion   of  sight,  especially  when   he  looks   toward   the  left. 


432  DISEASES   OF    THE    EYE. 

To  decide  the  diagnosis  in  such  a  case  the  double  images  must 
be  examined.  A  long,  lighted  candle  is  used  as  the  object  to  be 
looked  at ;  and  one  eye — let  us  say  here  the  left  eye  — is  covered 
with  a  bit  of  red  stained  glass,  in  order  to  differentiate  the 
images.'^  The  candle  is  now  held  on  a  level  with  the  patient's 
eyes,  and  straight  opposite  him,  at  about  three  metres  distance 
(eyes  in  primary  position),  a.  In  this  position  the  images  are 
seen  very  close  together,  or  overlapping  each  other,  both  of 
them  upright  and  on  the  same  level,  the  red  candle  to  the  left, 
the  white  to  the  right,  i.  e.,  homonymous  diplopia  =  convergence. 
This  convergence  must  be  due  to  paralysis  of  one  or  other 
external  rectus  muscle,  but  we  cannot  say  at  this  stage  of  the 
experiment  which  of  them  is  affected,  h.  In  order  to  determine 
this  point,  the  candle  must  be  carried  from  side  to  side,  and  the 
increasing  or  decreasing  distance  of  the  images  from  each  other 
noted.  If  the  candle  be  carried  slowly  to  the  right,  the  patient 
following  it  with  his  eyes  while  his  head  remains  fixed,  the 
images  come  still  closer  together,  or  only  one  candle  is  seen. 
But  if  the  candle  be  carried  to  the  patient's  left-hand  side,  the 
images  go  further  apart,  their  relative  positions  being  main- 
tained. We  now  know  that  it  is  the  left  external  rectus  which 
is  affected,  because  toward  the  left — the  direction  in  which  the 
action  of  this  muscle  is  most  wanted,  and  consequently  its  loss 
most  felt^-the  distance  between  the  double  images  increases. 
The  images  are  erect,  as  no  wheel-motion 
is  caused  by  action  of  the  external  rectus,  c. 
If,  however,  the  candle  be  held  to  the  left  and 
raised  aloft,  the  image  belonging  to  the  left 
eye  w^ill  seem  to  lean  away  from  that  of  the 
right  eye  (Fig.  145).  The  reason  of  this  is, 
that,  owing  to  the  paralysis  of  the  external 
rectus,  the  left  eye  cannot  look  upward  and 
outward    as    it    should,    but    merely    looks 


*  Maddox's  Rod  Test,  described  further  on,  is  very  suitable  here,  and 

in  the  investigation  of  other  forms  of  ocular  palsy. 


THE    ORBITAL   MUSCLES.  433 

upward.  The  vertical  meridian  therefore  remains  vertical. 
But  the  right  eye,  which  is  free  to  follow  the  candle,  looks  up 
and  to  the  left.  Its  vertical  meridian  is  therefore  inclined  to 
the  left.  That  is,  the  vertical  meridians  of  the  two  eyes 
converge  at  the  top,  which  necessitates  a  divergence  of  the 
upper  extremities  of  the  images.  The  rotation  of  the  right  eye 
in  this  position  is  physiological,  and  its  image  is  therefore  judged 
to  be  vertical,  while  the  image  of  the  left  eye  diverging  from 
that  of  the  right,  though  really  vertical,  is  judged  to  be  oblique. 
An  analogous  derangement  of  the  vertical  meridian  takes  place 
in  the  position  below  and  to  the  outside,  d.  If  the  patient  be 
told  to  direct  his  gaze  specially  toward  the  red  candle  the  dis- 
tance between  the  two  candles  will  be  much  greater  than  if  he 
direct  his  gaze  toward  the  white  candle.  This  is  explained  by 
General  Principle  No.  2,  p.  430. 

If  the  patient's  good  eye  be  closed,  and  an  object  (surgeon's 
finger)  be  held  up  within  his  reach,  but  toward  his  left-hand  side, 
and  he  be  requested  to  aim  rapidly  at  it  with  his  fore-finger,  he 
will  aim  to  the  left  of  it.  The  nervous  impulse  sent  to  his  left 
external  rectus,  to  enable  him  to  turn  the  eye  toward  the  object, 
is  of  such  intensity  as  to  lead  him  to  fancy  that  the  object  lies 
much  further  to  the  left  than  it  does  (incorrect  projection  of  the 
field  of  view)  ;  for  we,  to  a  great  extent,  estimate  the  distance  of 
objects  from  each  other  by  the  amount  of  nervous  impulse  sup- 
plied to  our  orbital  muscles  in  motions  of  the  eyeball. 

A  prism  held  horizontally  before  the  affected  eye,  with  its 
base  outward,  brings  the  double  images  closer  together ;  or,  if 
the  correct  prism  be  selected,  the  images  will  be  blended  into  one. 

Paralysis  of  the  Superior  Oblique  of  the  Left  Eye. — This 
paralysis  will  be  most  apparent  when  a  demand  is  made  for 
motion  of  the  eyeball  downward  and  inward,  motion  in  this  direc- 
tion being  that  over  which  the  superior  oblique  has  most  influ- 
ence. Still,  absolute  defect  of  motion  is  sometimes  difficult  to 
detect,  even  in  complete  paralysis  of  this  muscle,  owing  to  vica- 
rious action  of  the  inferior  rectus  and  internal  rectus.     Careful 


434  DISEASES   OF   THE   EYE. 

examination  of  the  secondary  deviation  will  often  be  successful 
as  to  this  point,  but  it  is  the  examination  of  the  double  images 
upon  which  we  must  chiefly  depend  for  the  diagnosis. 

a.  In  the  whole  of  the  field  of  vision  above  the  horizontal 
plane  there  is  single  vision.  Below  the  horizontal  plane  in  the 
median  line  diplopia  appears,  the  image  belonging  to  the  left  eye 
standing  lower  than  that  belonging  to  the  right,  because  the 
superior  oblique  being  a  muscle  which  assists  in  rotating  the  eye 
downward,  the  latter,  for  want  of  the  action  of  this  muscle,  now 
stands  higher  than  its  fellow  (right  eye),  and,  consequently,  the 
image  will  not  fall  on  its  macula  lutea  (as  it  does  in  the  right 
eye),  but  above  it,  and  will  therefore  be  projected  below  the 
image  of  the  right  eye.  The  position,  downward  and  inward, 
of  the  eyeballs  is  that  in  which  the  greatest  demand  is  made  upon 
the  superior  oblique  for  rotation  of  the  eye  downward  :  therefore, 
it  is  in  this  position  its  want  for  this  purpose  is  most  felt,  and 
when  the  candle  is  held  in  this  position  the  vertical  distance 
between  the  double  images  is  greatest,  b.  The  superior  oblique 
assists  also  in  rotation  of  the  eye  outward :  therefore,  loss  of  its 
power  must  commit  the  eyeball,  to  a  certain  extent,  to  the  power 
of  the  muscles  which  move  it  inward,  and  a  rotation  in  this  latter 
direction  (convergence)  takes  place,  with  the  result  of  making 
the  image  belonging  to  the  left  eye  stand  to  the  left  of  the  image 
belonging  to  the  right  eye  (homonymous  diplopia),  c.  The 
superior  oblique  inclines  the  vertical  meridian  inward :  there- 
fore, in  rotation  directly  downward,  loss  of  its  power  commits  the 
eye  to  the  outward  wheel-motion  imparted  to  it  by  the  inferior 
rectus.  This  gives  to  the  image  belonging  to  the  left  eye  an  in- 
clination to  the  patient's  right  hand.  d.  The  power  of  the  supe- 
rior oblique  to  incline  the  vertical  meridian  inward  is  greatest 
when  the  eye  is  turned  downward  and  outward  ;  consequently, 
in  this  respect  its  paralysis  will  be  most  felt  in  this  position,  and 
therefore  here  the  inclination  of  its  image  to  that  of  the  sound 
eye  will  be  most  marked,  e.  A  remarkable  phenomenon  usually 
noticed  in  this  paralysis  (and  sometimes  in  paralysis  of  the  infe- 


THE   ORBITAL    MUSCLES.  435 

rior  rectus),  and  for  which  a  good  explanation  does  not  exist, 
is,  that  the  image  belonging  to  the  affected  eye  seems  to  stand 
nearer  the  patient  than  that  of  the  sound  eye. 

To  sum  up,  then  (vide  Fig.  146)  : 
below  the  horizontal  plane  there  is  ^^* 

homonymous    diplopia,   while   the  Q 

image  (A)  of  the  affected  eye 
stands  on  a  lower  level,  is  inclined 
toward  the  other  image,  and  seems 
to  be  nearer  the  patient.  Further- 
more : — 

/.  In  an  extreme  lower  and  outer 
position  the  image  of  the  affected 
eye  may  sometimes  seem  to  stand  higher  than  that  of  the  sound 
eye,  owing  to  an  excessive  outward  inclination  of  the  vertical 
meridian,  which  throws  the  image  on  the  lower  and  outer  quad- 
rant of  the  retina. 

In  order  to  do  away  with  or  to  diminish  the  diplopia  the 
patient  inclines  his  head  forward  and  turns  it  to  the  side  of  the 
good  eye. 

For  the  prismatic  correction  of  the  diplopia  two  prisms  will 
be  required,  one  with  its  base  downward  in  front  of  the  left 
eye  to  correct  the  vertical  difference,  and  a  second  with  its 
base  outward  in  front  of  the  right  eye  to  correct  the  lateral 
difference. 

To  make  the  diagnosis  between  the  foregoing  paralysis  and 
paralysis  of  the  left  inf.  rectus, — in  which  the  diplopia  is  also 
below  the  horizontal  plane  only  and  the  image  of  the  left  eye 
also  lower  than  that  of  the  right,— it  has  merely  to  be  remem- 
bered that  there  is  here  crossed — instead  of  homonyrnous — diplo- 
pia, because  the  superior  oblique,  which  now  chiefly  effects  the 
downward  motion  of  the  eyeball,  turns  it  at  the  same  time  some- 
what outward,  and  that  the  image  of  the  left  eye  is  inclined 
toward  the  left  instead  of  toward  the  right,  because  the  inf. 
rectus  inclines  the  vertical  meridian  outward,  and,  therefore, 
when  its  action  is  lost  the  eye  is  committed  to  the  action  of  the 


436  DISEASES   OF   THE    EYE. 

superior  oblique,  which  gives  it  a  wheel- motion  inward.     The 
figures  147  and  148  will  assist  in  this  explanation. 

Paralysis  of  the  Internal  Rectus,  Superior  Rectus,  Inferior 
Rectus,  Inferior  Oblique,  and  Levator  Palpebrae. — Complete 
paralysis  of  all  the  branches  of  the  third  nerve  produces  a  re- 
markable appearance.  The  upper  lid  droops  (ptosis),  the  pupil 
is  semi-dilated  and  immovable,  the  power  of  accommodation  is 
destroyed,  and  the  eyeball  is  often  slightly  protruded,  owing  to 
the  backward  traction  of  the  recti  being  lost  to  it.  Motion  in- 
ward exists  but  to  a  slight  degree,  and  motion  downward  is 
effected  only  by  aid  of  the  superior  oblique,  and  is  accompanied 
by  marked  inward  wheel-motion.     If  the  paralysis  be  of  some 

Fig.  147.  Fig.  148. 


Fig.  147. — Paralysis  of  Left  Inf.  Rectus.  Crossed  diplopia.  A, 
image  of  right  eye ;  B,  Image  of  left  eye. 

Fig.  148. — Paralysis  of  Left  Superior  Oblique.  Homonymous  diplo- 
pia.   A^,  Image  of  right  eye  ;  B^,  Image  of  left  eye. 

little  standing  the  external  rectus  obtains  rule  over  the  eyeball 
and  rotates  it  permanently  outward. 

The  diagnosis,  then,  in  cases  of  complete  paralysis  of  all 
branches  of  the  nerve  is  easily  made ;  but  not  so,  sometimes, 
if  the  paralysis  be  only  partial.  The  examination  of  the  double 
images  then  is  of  value.  If  (see  Fig.  149)  the  left  third  nerve 
be  partially  paralyzed  in  all  or  most  of  its  branches,  there  will 
be  crossed  diplopia,  either  in  the  whole  of  the  field  of  vision 
— for  want  of  power  in  the  internal  rectus — or  toward  the 
patient's  right   at  the  least,  and  the   lateral  distance  between 


THE   ORBITAL   MUSCLES. 


437 


the  images  will  increase  as  the  visual  object  is  carried  further 
toward  the  right.  When  the  visual  object  is  held  aloft,  the 
left  eye  will  remain  behind — for  want  of  the  action  of  both  of 
the  muscles  which  turn  the  eye  upward — and,  consequently,  in 
this  position  its  image  will  stand,  not  only  to  the  right  of,  but 
also  above  that  of  the  right  eye,  while,  when  the  visual  object 
is  held  below  the  horizontal  plane,  the  eye  will — owing  to 
paralysis  of  the  inferior  rectus — remain  higher  than  the  right 
eye,  and,  consequently,  its  image  will  appear  to  be  lower  than 
that  of  the  right  eye.     It  will,  moreover,  be  inclined  toward  the 

Fig.  149. 


latter  image,  in  consequence  of  the  inward  wheel-motion  im- 
parted to  the  eye  by  the  superior  oblique. 

When  in  each  eye  some  branches  of  the  third  are  paralyzed, 
the  diagnosis  is  often  extremely  complicated.  The  ptosis,  how- 
ever, which  is  nearly  always  present  and  is  readily  recognized, 
and  the  paralysis  of  the  sphincter  iridis  (mydriasis)  and  of 
accommodation,  which  often  exist  and  are  also  easily  observed, 
give  valuable  aid.  Moreover,  any  loss  of  motion  upward  must 
be  due  to  paralysis  of  the  third  nerve  ;  but  if  there  be  loss 
of  motion  downward  the  differential  diagnosis  between  paralysis 


438 


DISEASES    OF    THE    EYE. 


Left 
Sup.Hect. 


Rtght 
Sup.Mcpt. 


Left 
I/ifllect 


Inf.  nect 


of  the  inferior    rectus  and  of  the   superior  oblique  has  to  be 
made.     For  this  see  the  paragraph  on   paralysis  of  the  latter 

muscle  (p.  433). 
^^"    '^  '  As  may  be  imagined  from 

the  foregoing,  it  is  often  diffi- 
cult in  practice  to  keep  clearly 
before  one's  mind   the  differ- 
ent  actions    of    the    orbital 
muscles,  and,  from  the  char- 
acter of  the  diplopia,  to  de- 
duce the  paralysis  which  may 
be  present.     An  aid  in  this 
respect  has  been  provided  by 
Dr.  Louis  Werner*  by  means 
of  two  diagrams  (Figs.  150 
and  151). 
The  form  of  diplopia  which  characterizes  paralysis  of  each 
muscle  is  expressed  by  the  position  of  the  dotted  line  bearing  the 
name   of    the    muscle.     The 
dotted    lines    represent    the  ^^" 

"  false  images,"  the  continu- 
ous lines  the  "  true  images."  f 
In  the  case  of  the  recti 
(Fig.  150)  the  false  images  en- 
close a  lozenge-shaped  space 
situated  between  the  true 
ones,  whereas  in  the  case  of 
the  oblique  muscles  (Fig.  151) 
the  true  images,  which,  for 
the  sake  of  simplicity,  are 
combined  in  one  line,  lie  be- 
tween the  four  "false  im- 
ages," which  diverge  from  one  another  so  as  to  form  an  X 


Left 
Inf.'OU. 


litght 
Inf   OU 


Left 
Sap  OU. 


Jlighb 
Sup.  OU. 


It 


*  Ophthalmic  Review^  March,  1886. 

t  The  "false  image"  corresponds  to  the  affected  eye,  and  the  "true 
image"  to  the  sound  eye. 


THE    ORBITAL   MUSCLES.  439 

will  also  be  noted  that  the  dotted  lines  extend  upward  and  down- 
ward beyond  the  others,  indicating  respectively  that  the  "  false 
images"  are  higher  or  lower  than  the  true  ones.  Another  fact 
which  the  diagrams  indicate  is  that,  in  the  case  of  the  muscles 
represented  in  the  upper  halves  of  the  figures,  the  diplopia  occurs 
in  the  upper  part  of  the  field  of  fixation,  or,  in  other  words,  in 
upward  movements  of  the  eyes.  A  similar  rule  holds  good  with 
regard  to  the  lower  halves. 

The  method  of  using  the  diagrams  will  be  better  understood 
by  taking  a  particular  muscle  as  an  example.  Suppose,  for  in- 
stance, that  we  wish  to  know  what  kind  of  diplopia  results 
from  paralysis  of  the  left  inferior  rectus;  it  is  simply  necessary 
to  look  at  the  left  inferior  portion  of  Fig.  150  (recti),  which  gives 
the  diplopia.  If  we  analyze  this  we  find  :  (1)  That  the  diplopia 
is  "  crossed,'"  for  the  false  image  corresponding  to  the  left  eye  is 
on  the  7nght  of  the  true  image,  i.  e.,  the  right  image  corresponds 
to  the  left  eye ;  (2)  that  the  false  image  has  its  upper  end  in- 
clined toward  the  true  one;  (3)  that  the  false  image  is  lower  than 
the  true  one,  for  the  dotted  line  extends  lower  than  the  other  one ; 
(4)  that  the  diplopia  occurs  in  downward  movements  of  the  eyes, 
for  it  is  in  the  lower  half  of  the  diagram  that  the  false  image  lies. 

The  same  method  applies  to  the  other  recti :  the  diplopia  for 
the  right  upper  rectus  is  found  in  the  right  upper  quadrant,  and 
so  on  for  the  rest. 

The  same  rules  also  apply  to  the  obliques  (Fig.  151),  with  one 
difference.  The  recti  move  the  eye  in  the  direction  indicated  by 
their  names,  the  superior  moving  it  upward  and  the  inferior 
downward ;  but  in  the  case  of  the  obliques  the  reverse  takes 
place,  the  superior  oblique  moving  the  eye  downward  and  the 
inferior  upward.  Therefore,  for  the  superior  obliques  we  must 
look  at  the  lower  half  of  Fig.  151,  and  for  the  inferior  obliques  at 
the  upper  part. 

This  is  an  extremely  simple  method.  By  bearing  the  figures 
in  mind,  it  is  possible  to  tell  immediately  what  kind  of  diplopia 
would  result  from  paralysis  of  any  one  of  these  muscles,  and  con- 
versely, given  the  diplopia,  to  determine  to  which  muscle  it  is  due. 


440  DISEASES    OF    THE    EYE. 

The  Causes  of  Peripheral  Paralyses  of  Orbital  Muscles  are 
chiefly  of  rheumatic  or  syphilitic  nature. 

Rheumatic  paralysis,  to  which  the  external  rectus  is  specially 
prone,  will  be  noted  if  there  are  symptoms  of  general  rheuma- 
tism, or  if  there  is  a  history  of  exposure  to  cold  or  wet  immedi- 
ately preceding  the  attack. 

Syphilis  will  be  suggested  as  a  cause,  if  there  be  a  specific 
history,  and  that  other  causes  can  be  excluded.  Peripheral 
paralyses  of  the  orbital  muscles  due  to  syphilis  are  amongst  the 
later  symptoms  of  the  disease,  and  may  depend  on  exostoses  or 
gummata  at  the  base  of  the  skull,  or  to  syphilitic  neoplasms,  or 
meningitis  in  the  course  of  the  nerve.  The  third  nerve  seems 
to  be  particularly  liable  to  be  attacked  by  a  solitary  gumma  at 
the  base  of  the  skull,  especially  at  the  sphenoidal  fissure,  ptosis 
being  commonly  the  first  symptom. 

Other  neoplastic  growths  can,  of  course,  cause  these  paralyses 
in  the  same  way. 

Prognosis. — In  peripheral  paralyses  recovery  is  very  frequent, 
much,  however,  depending  on  the  nature  of  the  lesion.  In  cases 
where  a  cure  is  not  effected  the  antagonist  muscle  often  becomes 
contracted,  and  the  eye  is  then  rotated  permanently  and  exces- 
sively in  the  corresponding  direction.  In  cases  of  old  standing 
a  permanent  contraction  of  the  muscles  of  the  neck  may  be 
brought  about  from  the  inclination  of  the  head  which  the 
diplopia  has  obliged  the  patient  to  adopt. 

Treatment. — In  these  cases  the  medical  treatment  consists  in 
drugs  suitable  to  the  fundamental  disease  (rheumatism,  syphilis, 
etc.).  Local  depletion  at  the  temple  by  the  artificial  leech  in 
the  early  stages,  and  galvanism  later  on,  may  be  employed  with 
advantage.  The  most  common  method  of  applying  galvanism 
is  through  the  closed  lid,  but  it  is  probable  that  the  episcleral 
method,  i.  e.,  with  the  electrode  placed  directly  over  the  muscle, 
is  more  effectual,  and,  by  aid  of  cocaine,  this  can  now  be  done 
painlessly.     Dr.  Buzzard's  method  *  seems  to  be  a  very  admir- 

*  Trans.  Ophth.  Sac,  vol.  ix,  p.  191. 


THE    ORBITAL   MUSCLES.  441 

able  one.  He  applies  a  moistened  plate  rheophore  to  the  nape 
of  the  patient's  neck  and  connects  it  with  one  pole  of  a 
Leclanche  battery.  He  then  takes  the  other  rheophore,  well 
wetted,  in  his  left  hand,  and,  securing  good  contact  with  the  skin 
of  his  palm,  applies  the  index  finger  of  his  right  hand  to  the 
patient's  globe,  in  the  situation  of  the  various  external  muscles 
of  the  eye.  The  finger  is  covered  with  a  single  thickness  of 
well-moistened  muslin  ;  the  conjunctiva  should  be  previously- 
rendered  insensitive  by  cocaine.  The  strength  of  the  current 
advised  is  from  1.5  to  2  milliamperes,  and  the  alternate  applica- 
tion and  lifting  of  the  finger,  by  closing  and  opening  the  circuit, 
gives  rise  to  a  feeling  of  a  slight  electric  shock  in  the  terminal 
point  of  the  finger.  The  operator  should  first  test  the  strength 
of  the  current  upon  the  patient's  cheek.  The  point  of  the  finger 
thus  employed  acts  as  a  sentient  rheophore,  and  can  be  applied 
with  nicety  and  delicacy  to  various  parts  of  the  eye,  the  operator 
being  constantly  aware,  by  the  feeling  in  his  finger,  of  the 
strength  of  the  current  employed. 

Passive  orthopaedic  treatment*  occasionally  gives  a  rapid  and 
brilliant  result,  while  again  it  is  useless.  It  is  performed  as 
follows:  The  conjunctiva  at  the  corneo-scleral  margin,  near  the 
insertion  of  the  paralyzed  muscle,  is  seized  with  a  forceps  and 
the  eyeball  is  drawn  in  the  direction  of  the  muscle,  and  as  far 
as  possible  beyond  its  ordinary  limit  of  contraction,  and  back 
again.  These  movements  are  continued  for  about  a  minute, 
once  a  day,  and  cocaine  is  used. 

Prismatic  glasses  may  be  used,  either  to  eliminate  the  diplopia 
or  to  excite  the  weak  muscle  to  exert  itself.  In  the  former  case, 
the  glass  selected  must  completely  neutralize  the  diplopia ;  but, 
as  it  can  do  so  only  for  one  position  of  the  eyes,  prisms  are  rarely 
employed  in  this  way.  In  the  latter  case  a  prism  slightly 
weaker  than  that  sufficient  to  completely  neutralize  the  diplopia 
is  selected,  in  order  that,  with  a  little  effort,  the  weak  muscle 

*  First  proposed  by  Prof.  J.  Michel,  Klin.  Monatshl.  f.  Augenheilk., 
1887,  p.  373. 


442  DISEASES   OF   THE    EYE. 

may  be  enabled  to  bring  about  single  vision,  and  this  effort 
having  been  successfully  maintained  for  some  days,  a  still  weaker 
prism  is  then  prescribed,  and  so  on. 

It  is  very  important  for  the  patient's  comfort  while  awaiting 
his  cure,  unless  a  cure  by  prisms  as  above  described  is  being 
attempted,  that  the  affected  eye  should  be  covered,  so  that  the 
distressing  double  vision  may  be  obviated. 

Surgical  treatment  is  justifiable  only  when  other  means  have 
failed  to  restore  muscular  equilibrium.  If  the  deviation  amount 
to  3  or  4  mm.,  tenotomy  of  the  antagonistic  muscle,  with  subse- 
quent tenotomy  of  the  associate  muscle  in  the  other  eye,  will  be 
sufficient ;  but  if  the  deviation  amount  to  5  or  6  mm.,  advance- 
ment of  the  paralyzed  muscle  in  addition  to  the  tenotomy  may 
be  required.  This  surgical  treatment,  applied  to  the  internal 
and  external  rectus,  gives  satisfactory  results,  but  in  case  of  the 
superior  and  inferior  recti  it  is  not  so  satisfactory,  while  the 
oblique  muscles  should  not  be  operated  on. 

A  peculiar  and  rare  form  of  peripheral  paralysis  is  Intermit- 
ting Paralysis  of  one  Third  Xerve.  The  patients  are  generally 
children  or  young  adults  who  usually  suffer  from  headache  on 
the  side  corresponding  to  the  paralyzed  eye.  The  paralysis  may 
be  complete  or  partial  and  the  attack  varies  in  its  duration  from 
a  few  days  to  a  few  months.  Some  cases  are  purely  periodical, 
i.  e.,  in  the  intervals  between  the  attacks  of  paralysis  all  the  mus- 
cles supplied  by  the  third  nerve  act  in  a  completely  normal 
manner,  while  in  other  cases  those  muscles,  or  some  of  them,  do 
not  completely  recover  their  functions  in  the  intervals.  We  are 
as  yet  quite  in  the  dark  as  to  the  cause  of  these  periodical  paral- 
yses of  the  third  nerve.  Some  hold  that  the  purely  periodical 
cases  are  of  a  functional  nature,  possibly  hysterical  or  reflex, 
and  that  the  periodically  exacerbating  cases  alone  are  due  to  a 
lesion  of  the  root  of  the  nerve  of  an  undefined  kind  at  the  base 
of  the  skull,  while  others  are  of  opinion  that  both  forms  depend 
upon  a  diseased  process  at  the  base. 

In  intermitting  paralysis  tJie  Prognosis  of  the  purely  peri- 
odical form  is  favorable,  inasmuch  as  the  attacks  in  the  course 


THE   ORBITAL   MUSCLES.  443 

of  time  become  fewer  and  less  severe,  until,  finally,  they  cease 
entirely.  In  the  exacerbating  form  the  prognosis  for  complete 
recovery  is  less  favorable. 

In  view  of  the  obscurity  which  still  surrounds  the  causation  of 
these  intermitting  paralyses,  their  Treatment  must  consist,  in  each 
case,  in  the  relief  of  any  general  dyscrasia  or  concomitant 
symptoms  which  may  be  present. 

The  third  class  of  paralyses  of  orbital  muscles  above  enumer- 
ated— those  due  to  lesions  of  the  nuclei  of  the  orbital  muscles, 
in  the  aqueduct  of  Sylvius,  and  floor  of  the  fourth  ventricle — 
are  known  by  the  term 

Ophthalmoplegia  Externa,  and  also  as  Nuclear  Paralysis. — 
The  first  of  these  terms  was  originally  employed  to  denote  those 
remarkable  cases  in  which  all,  or  nearly  all,  the  orbital  muscles 
of  both  eyes  are  paralyzed,  while  the  intraocular  muscles  often 
remain  intact.  There  can  be  no  doubt,  however,  that  these  cases 
do  not  diflfer  in  their  nature  from  many  of  those  in  which,  in  one 
eye,  several  orbital  muscles  supplied  by  difl^erent  nerves,  e.  g., 
the  third  and  fourth,  are  wholly  or  partially  paralyzed  ;  or 
where  all  the  orbital  muscles  in  one  eye  are  wholly  or  partially 
paralyzed  ;  or  where  in  each  eye  muscles  supplied  by  the  same 
nerve,  e.  g.,  both  sixth  nerves,  are  wholly  or  partially  paralyzed ; 
for  such  cases  are  often  mild  forms  of  the  disease  or  else  stages 
in  its  development.  At  one  time  it  was  considered  essential  for 
the  diagnosis  that  the  intraocular  muscles  should  retain  their 
functions,  but  cases  occur  in  which  the  sphincter  iridis  and  cili- 
ary muscles  are  paralyzed. 

When  these  two  latter  muscles  alone  are  paralyzed  the  condi- 
tion is  called  Ophthalmoplegia  Interna.  When  both  they  and 
groups  of  orbital  muscles  are  paralyzed  the  terms  Ophthalmo- 
plegia Interna  et  Externa,  or  Ophthalmoplegia  Universa,  are 
employed. 

The  term  Nuclear  Paralysis  indicates  any  orbital  paralysis 
due  to  a  lesion  of  the  nuclei  of  the  orbital  nerves  in  the  pons, 
and  ophthalmoplegia  externa  comes  within  this  category. 

The  ptosis,  even  in  cases  of  complete  binocular  ophthalmo- 


444  DISEASES    OF   THE    EYE. 

plegia  externa,  is  often  incomplete,  and  it  is  remarkable  that  in 
some  chronic  cases,  without  any  improvement  in  the  condition 
itself,  the  diplopia,  which  was  at  first  present,  quite  disappears. 

Occurrence  and  Progress. — The  condition  may  be  congenital, 
or  may  make  its  appearance  soon  after  birth,  and  may  remain 
permanently  without  becoming  complicated  with  any  further 
disturbance.  Congenital  ptosis,  which  is  frequently  combined 
with  loss  of  power  in  the  superior  rectus,  and  is  usually  binocular, 
is  of  this  nature.  But  Nuclear  Paralysis  is  more  commonly  seen 
as  an  acquired  condition  in  childhood  or  in  adult  life,  either  in 
an  acute  or  chronic  form.  Marked  cerebral  lethargy  is  often 
seen  with  both  forms,  and  the  tendon  reflexes  may  be  defective. 

Acute  Nuclear  Paralysis  is  due  either  to  an  acute  inflamma- 
tory process  in  the  nuclei — comparable  to  the  process  which 
produces  polio-myelitis  anterior  acuta,  and  hence  it  is  called 
by  Byrom  Bramwell  polio-myelitis  acuta — or  to  hemorrhagic 
lesions. 

The  acute  inflammatory  cases  are  apt  to  have  a  sudden 
onset,  attended  with  fever,  headache,  vomiting,  and  convul- 
sions, which  may  subside  after  a  few  days,  leaving  only  the 
ophthalmoplegia  behind  ;  and  this,  too,  after  a  lengthened 
period,  may  undergo  cure,  partial  or  complete.  Sometimes 
these  attacks  are  complicated  with  paralysis  of  the  facial 
nerve,  or  the  diseased  process  may  extend  to  the  spinal  cord, 
and  the  symptoms  of  acute  polio-myelitis  become  developed ; 
or,  again,  acute  bulbar  paralysis  may  come  on. 

Acute  peripheral  neuritis  of  the  ocular  nerves,  which  is 
sometimes  seen  in  cases  of  alcoholic  poisoning,  may  be  con- 
founded with  acute  nuclear  palsy.  The  symptoms  of  the 
two  states  are  the  same,  except  that  in  the  cases  of  peripheral 
neuritis  there  are  no  head  symptoms  at  the  commencement. 

The  onset  of  acute  hemorrhagic  ophthalmoplegia  is  sudden, 
but  unattended  by  headache,  vomiting,  or  convulsions.  It 
takes  different  courses.  Sometimes  it  is  rapidly  fatal,  again' it 
goes  on  to  softening  of  the  nuclei  and  becomes  chronic,  while 
again  it  undergoes  a  slow  cure. 


THE   ORBITAL   MUSCLES.  445 

It  is  extremely  probable  that  to  this  hemorrhagic  class  the 
paralyses  of  orbital  muscles  belong  which  sometimes  follow 
on  an  attack  of  diphtheritic  sore  throat.  These  paralyses  appear 
in  from  one  to  six  weeks  after  the  outbreak  of  the  primary 
affection.  The  latter  need  not  have  been  of  a  severe  kind  ; 
indeed,  sometimes  patients  are  unaware  that  they  have  had 
a  sore  throat.  These  diphtheritic  paralyses  always  recover 
in  the  course  of  some  weeks. 

In  diabetes,  paralyses  of  orbital  muscles  are  not  very  un- 
common, and  are  probably  to  be  classed  as  nuclear.  The 
same  may  be  said  of  orbital  paralyses  in  lead-poisoning  and 
in  epidemic  influenza  ("  la  grippe  "). 

The  Prognosis  in  all  these  instances  is  very  favorable. 

Chronic  Nuclear  Paralysis  is  much  more  common  than  the 
acute  form.  It  depends  on  a  degenerative  atrophy  of  the 
nerve  nuclei,  analogous  to  that  which  occurs  in  progressive 
muscular  atrophy  and  in  chronic  bulbar  paralysis.  The 
onset  is  gradual,  the  loss  of  power  in  the  muscles  being  at 
first  very  slight,  but  ultimately  complete  paralysis  of  the 
affected  muscles  results.  There  is  no  fever  nor  any  cerebral 
symptom.  The  condition  may  become  associated  with  chronic 
bulbar  paralysis,  with  progressive  muscular  atrophy,  or  with 
locomotor  ataxy. 

Coarse  lesions,  especially  tumors  of  the  pons  and  of  its  neigh- 
borhood which  press  on  it,  may  produce  orbital  paralyses 
closely  simulating  those  due  to  nuclear  lesions.  But  here 
the  paralysis  is  only  one  of  the  symptoms  in  the  case,  which 
are  likely  to  include  headache,  vomiting,  optic  neuritis, 
hemianopsia,  hemiplegia,  etc.  Softenings,  patches  of  dissemi- 
nated sclerosis,  and  internal  hydrocephalus  with  over-distention 
of  the  aqueduct  of  Sylvius,  are  other  lesions  which  may  give  rise 
to  similar  orbital  paralyses,  but  which  cannot  be  regarded  as 
true  nuclear  ophthalmoplegia.  The  mode  of  onset  and  the  con- 
comitant symptoms  of  each  case  must  serve  as  our  guides  in  ar- 
riving at  a  diagnosis,  which  will  sometimes  be  difficult  enough. 


446  DISEASES   OF   THE   EYE. 

Conjugate  Lateral  Paralysis  of  the  eyes  is  a  symptom  which 
may  be  caused  by  a  lesion  in  the  pons.  We  believe  that  the 
voluntary  motor  impulses,  coming  down  from  the  cortex  to  pro- 
duce associated  lateral  motions  of  the  eyeballs — i.  e.,  action  of 
the  external  rectus  of  one  eye,  along  with  action  of  the  internal 
rectus  of  the  other  eye — first  reach  the  nucleus  of  the  sixth 
nerve  and  then  pass  on  through  fibres  called  the  posterior  longi- 
tudinal bands,  under  the  corpora  quadrigemina,  and  join  with 
the  fibres  of  the  opposite  third  pair  for  the  supply  of  the  internal 
rectus  of  that  side.  The  sixth  pair  of  one  side  supplies  in  this 
way  the  external  rectus  of  its  own  side,  and,  to  a  slight  extent, 
the  internal  rectus  .of  the  opposite  side,  and  it  is  quite  probable 
that  similar  decussations  may  exist  in  the  nerve  supply  of  other 
orbital  muscles.  Hence  a  lesion  at,  let  us  say,  the  left  sixth 
nerve  nucleus  would  paralyze  the  conjugate  lateral  motions  of 
the  eyes  toward  the  left  side,  and  there  would,  in  consequence, 
be  conjugate  lateral  deviation  of  the  eyes  toward  the  right — the 
eyes  look  away  from  the  lesion.  In  conjugate  paralysis  or 
deviation,  whether  due  to  a  pontine  lesion,  or,  as  in  the 
next  paragraph,  to  a  cerebral  lesion,  the  combined  action  of 
the  internal  recti  for  the  purpose  of  convergence  of  the  eyes  is 
retained. 

Cerebral  Paralysis  of  Orbital  Muscles  form  the  fourth  and 
last  of  the  classes  enumerated.  They  include  all  the  orbital 
paralyses  due  to  lesions  above  the  nuclei,  i.  e.,  in  the  cortex, 
corona  radiata,  or  internal  capsule.  They  are  usually  associated 
with  other  symptoms  which  aid  us  in  localizing,  more  or  less  ac- 
curately, the  lesions  which  cause  them.  These  paralyses  are 
always  physiological,  associated,  or  conjugate,  as  they  are  vari- 
ously and  with  equal  correctness  termed — they  are,  in  short, 
paralyses  of  motion  rather  than  of  muscles.  Conjugate  lateral 
paralysis — loss  of  power  of  motion  of  the  eyes  to  one  side  or  to 
the  other,  while  the  power  of  convergence  of  the  optic  axes  is 
retained — is  by  far  the  most  common  form  of  this  symptom. 
We  do  not  as  yet  know  where  the  cortical  centre  for  the  asso- 


THE    ORBITAL    MUSCLES.  447 

ciated  lateral  motions  of  the  eyes  is  situated.  But,  eveu  if  we 
did  know  its  position,  it  is  not  likely  that  much  would  be  gained, 
so  far  as  clinical  localization  of  the  cerebral  lesion  is  concerned  ; 
for  this  centre,  wherever  it  may  be,  is  extremely  sensitive,  and  is 
apt  to  be  thrown  out  of  gear  by  lesions  of  many  different  parts 
of  the  cortex.  Conjugate  deviation  is,  in  short,  very  apt  to  be  a 
distant  symptom,  especially  in  cerebral  hemorrhage,  when  it  is 
often  accompanied  by  a  rotation  of  the  head  in  the  same  direc- 
tion and  lasts  only  a  short  time.  Moreover,  it  is  thought  that, 
when  this  centre  may  happen  to  be  actually  involved  in  the 
lesion,  its  function,  being  largely  bilateral,  is  rapidly  taken  up 
by  the  opposite  hemisphere,  and,  hence,  even  when  conjugate 
lateral  deviation  plays  the  part  of  a  direct  cortical  symptom,  it 
can  never  be  recognized  as  such,  owing  to  its  evanescent  charac- 
ter. In  paralyzing  lesions  the  deviation  of  the  eyes  is,  of  course, 
toward  the  side  of  the  lesion — the  eyes  look  at  the  cerebral 
lesion,  as  Prevost  has  expressed  it — while  in  irritating  lesions  the 
spasm  of  the  affected  muscles  causes  the  deviation  to  be  from  the 
side  of  the  lesion.  These  conditions  are  the  reverse  of  what  hap- 
pens in  conjugate  lateral  deviation  due  to  lesions  in  the  pons 
(p.  446),  and  we  are  thus  enabled  to  differentiate  between  lesions 
in  the  two  positions. 

There  are  four  possible  cases  : — 

p      h    1  T     ■         [Destructive.     Eyes  turned  away  from  paralyzed  side. 
I  Irritative.  "         "       toward  convulsed  side. 

■pv     ^.       T     •  f  Destructive.         "         "      toward  paralytic  side. 

Pontine  Lesions,  i^    .      .  ,,         ,,  r  t     j   -j 

•■Irritative.  away  irom  convulsed  side. 

The  cerebral  cases  show  that  the  centre  for  associated  movements 
is  on  the  opposite  side  of  the  brain,  e.  g.,  in  movements  of  eyes  to 
the  left,  the  left  external  rectus  and  right  internal  rectus  are  in- 
nervated by  the  right  hemisphere  of  the  brain,  consequently  a  de- 
structive lesion  here  would  produce  paralysis  of  the  left  side  of  the 
body,  and  of  the  associated  movements  of  the  above  orbital  mus- 
cles, and  therefore  the  eyes  would  be  drawn  to  the  right  by  their 
opponents,  i,  e.,  away  from  the  paralyzed  side.     A  destructive 


448 


DISEASES   OF   THE   EYE. 


Fig.  152. 


lesion  of  the  right  side  of  the  pons  would  also,  of  course,  pro- 
duce paralysis  of  the  left  side  of 
the  body ;  but,  involving  the 
right  sixth  nucleus,  it  would 
cause  paralysis  of  the  associated 
movements  of  the  right  external 
rectus  and  left  internal  rectus, 
and,  consequently ,  the  eyes  would 
be  drawn  to  the  left  by  the  op- 
ponents, i.  e.,  toward  the  para- 
lyzed side. 

The  reverse  of  the  foregoing 
would  occur  in  irritative  lesions. 
Fig.  152  will  serve  to  illustrate 
the  points  referred  to. 

A  destructive  lesion  at  12, 
the  right  cortical  centre,  involv- 
ing also  motor  centres  of  the 
body,  would  cause  left  hemiple- 
gia ;  and,  since  the  external 
rectus  of  the  left  eye  and  in- 
ternal rectus  of  the  right  eye 
would  be  paralyzed,  the  antago- 
nists would  turn  the  eyes  to  the 
right,  {.  e.,  away  from  the  para- 
lyzed side.  A  destructive  lesion 
of  the  right  side  of  the  pons, 
also  producing  left  hemiplegia, 
if  it  involve  the  sixth  nucleus, 
will  produce  paralysis  of  the  external  rectus  of  the  right  eye 
and  of  the  internal  rectus  of  the  left  eye,  and  then  the  antago- 
nists would  turn  the  eyes  to  the  left,  i.  e.,  toward  the  paralyzed 
side.  It  is  easy  to  see  how  irritative  lesions  would  produce  ex- 
actly the  opposite  effects. 

It  may  be  of  interest  here,  even  at  the  risk  of  some  repetition, 
to  direct  special  attention  to 


1.  Left  Ext.  Rectus;  2.  Left 
Int.  Rectus  ;  3.  Right  Int.  Rectus  ; 
4.  Right  Ext.  Rectus ;  5.  Nucleus 
left  third  nerve  ;  6.  Nucleus  right 
third  nerve  ;  7  and  8.  Post,  longi- 
tudinal bands  from  sixth  nerve  to 
opposite  third  nerve ;  9.  Nucleus 
left  sixth  nerve  ;  10.  Nucleus  right 
sixth  nerve  ;  11  and  12.  Left  and 
right  cortical  centres.  An  im- 
pulse starting  from  12  would  travel 
down  to  9,  and  produce  an  asso- 
ciated movement  of  the  eyes  to 
the  left. 


THE    ORBITAL   MUSCLES.  449 

The  Localizing  Value  of  Paralyses  of  Orbital  Muscles  in 
Cerebral  Disease. — Paralysis  of  the  Third  Nerve. — As  regards 
this  nerve,  we  are  struck  with  the  fact  that  ptosis,  partial  or 
complete,  may  be  present  as  a  focal  symptom  in  cortical  lesions 
— cerebral  ptosis,  as  it  is  called — without  any  other  third-nerve 
branch  being  paralyzed.  That  a  separate  cortical  centre  for  this 
branch  of  the  third  nerve  exists,  and  that  it  innervates  the  mus- 
cle of  the  opposite  side,  is  very  probable.  The  existence  of  such 
a  centre  would  not  be  inconsistent  with  the  view  that,  as  regards 
the  motions  of  the  eyeballs,  associated  centres  alone  are  present; 
for  although,  as  a  rule,  the  elevators  of  the  lids  are  associated  in 
their  motions,  yet  by  an  effort  of  the  will  most  people  can  throw 
one  of  them  into  motion  separately,  or  more  than  the  other.  IN'o 
doubt  the  power  to  voluntarily  innervate  one  levator  and  orbicu- 
laris alone  varies  in  different  individuals,  and  in  many  persons 
the  levator  centres  are  practically  associated  centres,  and  prob- 
ably this  is  the  reason  why  cerebral  ptosis  is  rather  rare.  The 
position  of  this  centre  is  still  an  open  question,  for  the  view  that 
it  is  situated  in  the  posterior  part  of  the  inferior  parietal  lobule 
has  not  met  with  general  acceptance. 

Ptosis,  then,  has  no  value  as  indicating  the  locality  of  a  lesion 
in  the  cortex ;  but  it  may  be  of  use  in  distinguishing  a  cortical 
lesion  from  one  situated  elsewhere  in  the  brain,  for  monolateral 
ptosis,  as  the  only  focal  symptom,  occurs  with  cortical  lesions 
alone. 

It  is  probable  that  ptosis,  as  the  result  of  a  cortical  lesion,  is 
a  distant  symptom  in  not  a  few  of  the  cases  where  it  is  present. 

Ptosis  on  the  side  of  the  lesion  has  occasionally  formed  a  symp- 
tom in  disease  of  the  pons,  without  paralysis  of  the  other  branches 
of  the  third  nerve — except,  sometimes,  in  so  far  as  conjugate 
deviation  (vide  sujjra)  is  concerned — and  without  the  third  nerve 
being  involved  in  the  lesion. 

Again,  ptosis,  by  forming  a  factor  of  a  crossed  paralysis,  may 

serve  to  localize  a  lesion  in   the  crus  cerebri.     When  the  third 

nerve  is  paralyzed  by  a  lesion  in  this  situation,  it  is  the  rule  to 

find  it  paralyzed  as  a  whole,  but  paralysis  of  only  some  of  the 

88 


450  DISEASES    OF    THE    EYE. 

third-nerve  branches  may  be  produced  by  a  lesion  of  the  cere- 
bral peduncle,  and  the  branch  to  the  levator  palpebrse  seems  to 
be  the  one  most  frequently  implicated  alone. 

In  order  now  to  complete  this  subject  of  ptosis  as  a  focal 
symptom,  I  must  refer  to  a  rare  form  of  it  which  has  been 
described  by  Nothnagel,  and  which  does  not  depend  on  a 
lesion  of  the  third  nerve.  It  may  be  called  sympathetic,  or 
pseudo-ptosis,  and  is  accompanied  by  other  eye-symptoms,  as 
well  as  by  symptoms  of  vasomotor  paralysis  of  one  side  of  the 
body,  such  as  elevation  of  temperature  and  redness  and  oedema 
of  the  skin.  In  these  cases,  this  author  says,  there  is :  1 . 
Apparent  ptosis  on  the  paralyzed  side,  owing  to  the  contraction 
of  the  palpebral  aperture,  but  the  lid  can  be  raised.  2.  Con- 
traction of  the  pupil  on  the  same  side.  3.  A  shrinking  back  of 
the  eyeball  into  the  orbit,  so  that  it  seems  to  have  become 
smaller.  4.  An  abnormal  secretion  of  thin  mucus  from  the 
corresponding  nostril,  of  tears  from  the  affected  eye,  and  of 
saliva  from  the  corresponding  side  of  the  mouth.  Nothnagel 
states  he  has  found  this  train  of  symptoms  in  lesions  of  the 
corpus  striatum. 

A  common  sign  of  disease  of  the  crus  cerebri  is  what  is  known 
as  crossed  hemiplegia.  Paralysis  of  the  third  nerve  on  the  side 
of  the  lesion,  with  hemiplegia,  hemiansesthesia,  often  facial,  and 
sometimes  hypoglossal,  paralysis  of  the  opposite  side  of  the  body 
is  a  frequent  form  of  it.  The  lesion  may  implicate  all  the 
branches  of  the  third  nerve  or  only  some  of  them.  But  the 
localizing  value  of  crossed  hemiplegia,  as  Hughlings  Jackson 
long  ago  pointed  out,  depends  chiefly  on  the  hemiplegia  and 
paralysis  of  the  cranial  nerve  coming  on  simultaneously.  If 
they  occur  at  different  times  they  may  be  due  to  two  distinct 
lesions,  neither  of  which  may  be  in  the  crus ;  for  the  hemi- 
plegia might  be  due  to  a  lesion  in  the  hemisphere,  and  the 
third-nerve  paralysis  to  a  basal  lesion  of  earlier  or  later  date. 
Yet  a  few  cases  have  been  observed  where,  with  a  lesion  in  the 
cerebral  peduncle,  the  third-nerve  paralysis  preceded  the  hemi- 
plegia by  a  considerable  interval. 


THE    ORBITAL    MUSCLES.  451 

That  basal  lesions  are  by  far  the  most  frequent  cause  of 
paralysis  of  the  third  nerve  is  beyond  a  doubt :  and  here  it  is 
usual,  but  not  constant,  to  find  it  paralyzed  in  all  its  branches. 
The  diagnosis  to  be  made,  when  direct  symptoms  are  being  con- 
sidered, is,  for  the  most  part,  between  a  lesion  in  the  crus  and 
a  lesion  at  the  base.  AVe  cannot  pretend  to  be  able  to  make 
this  diagnosis  with  certainty  in  all  cases.  Complete  paralysis 
of  every  branch  of  the  third  nerve  without  any  other  paralysis 
is  almost  always  basal ;  so  also  are  those  cases  in  which,  where 
there  is  hemiplegia,  it  is  slight  as  compared  with  the  degree  of 
the  third-nerve  paralysis ;  and  those  cases,  too,  to  which  I  heva 
already  referred,  where  there  is  an  interval  between  the  onset 
of  the  paralysis  of  the  extremities  and  of  the  third  nerve,  are 
apt  to  be  basal.  Of  course,  there  may  be  such  a  combination 
of  paralysis  of  the  other  cerebral  nerves  with  that  of  the  third 
nerve  as  to  leave  no  doubt  with  reference  to  the  basal  position 
of  the  lesion.     But  into  all  this  I  need  not  enter  here. 

Third-nerve  symptoms — in  addition  to  those  included  under 
the  headings,  conjugate  deviation,  or  paralysis  and  ptosis — are 
sometimes  distant  symptoms.  Tumors  of  the  cerebral  hemi- 
spheres, more  particularly  if  accompanied  by  violent  general 
head  symptoms,  indicating  probably  high  intracranial  pressure, 
are  the  lesions  most  apt  to  produce  these  distant  third-nerve 
symptoms.  As  a  rule,  the  slighter  the  general  cerebral  symp- 
toms are,  the  more  likely  are  the  third-nerve  paralyses  to  be 
direct  symptoms.  This  rule,  indeed,  applies  to  other,  as  well 
as  to  third-nerve,  focal  symptoms. 

Paralysis  of  the  Fourth  Xerve,  when  combined  with  paralysis 
of  other  motor  eye-nerves,  is  difficult  to  recognize,  and  con- 
sequently, in  such  cases,  it  supplies  but  little  aid  for  localization. 
Solitary  paralysis  of  this  nerve,  as  a  symptom  of  cerebral  focal 
lesion,  is  extremely  rare.  Xieden  has  placed  a  case  on  record 
in  which  paralysis  of  one  fourth  nerve  was  the  only  focal  symptom 
to  which  a  tumor  of  the  pineal  gland  of  the  size  of  a  walnut 
gave  rise.  But  the  isolated  fourth-nerve  paralysis  is  more  apt  to 
be  produced  by  a  basal    lesion.     In  combination  with  paralysis 


452  DISEASES   OF   THE   EYE. 

of  the  third  nerve  it  speaks  for  a  lesion  in  the  cerebral  peduncle 
extending  back  to  the  valve  of  Vieussens,  and  has,  I  believe, 
been  utilized  by  Meynert  in  this  sense. 

When  Paralysis  of  the  Sixth  Nerve  occurs  as  the  only  focal 
sign,  it  is  probably  due  to  disease  at  the  base,  or  it  is  a  distant 
symptom.  There  is  no  cranial  nerve  so  liable  to  provide  a  dis- 
tant symptom  as  the  sixth.  Gowers  refers  this  liability  to  the 
lengthened  course  these  nerves  take  over  the  most  prominent  part 
of  the  pons,  which  renders  them  readily  affected  by  distant  pres- 
sure. One  or  both  nerves  may  in  this  way  be  paralyzed.  Wer- 
nicke states  that  sixth-nerve  paralysis  is  most  apt  to  be 
present  as  a  distant  symptom  when  the  lesion,  especially  a 
tumor,  is  situated  in  the  cerebellum  ;  differing  in  this  way  from 
the  third  nerve,  which,  as  I  have  said,  is  more  likely  to  give 
distant  symptoms  with  a  lesion  in  the  cerebral  hemisphere. 

Paralysis  of  the  sixth  nerve,  simultaneous  in  its  onset  with 
hemiplegia  of  the  opposite  side  of  the  body,  indicates  a  lesion  in 
the  pons,  usually  a  hemorrhage,  on  the  side  corresponding  to  the 
paralyzed  nerve.  We  know  that  the  fifth  and  facial,  and  some- 
times the  auditory,  spinal  accessory  and  hypoglossal  nerves  may 
all,  in  varying  combinations,  form  one  of  the  elements  in  a 
crossed  paralysis  from  a  lesion  in  this  position,  but  if  special 
localizing  value  is  to  be  given  here  to  the  participation  of  any 
one  cranial  nerve,  that  nerve  is  the  sixth.  The  paralysis  of  this 
nerve,  simultaneously  with  palsy  of  the  opposite  side  of  the 
body,  while  other  conditions  point  to  an  intracranial  lesion, 
speaks  then  almost  certainly  for  pontine  disease. 

Paralysis  of  the  facial  with  the  sixth  is  not  an  uncommon 
combination  caused  by  a  lesion  in  the  pons,  which  at  the  same 
time  produces  hemiplegia  of  the  opposite  side  of  the  body. 
This  combination  is  a  natural  one,  in  view  of  the  close  relations 
of  the  nuclei  of  the  sixth  and  seventh  nerves.  Indeed,  Lock- 
hart  Clarke,  Meynert,  and  others  are  of  opinion  that  there  is 
one  nucleus  which  is  common  to  both  nerves,  a  view  not  shared 
in  by  Gowers  and  others.  The  manner  in  which  the  root  of  the 
facial  nerve  winds  round  the  sixth-nerve  nucleus  must  also  have 


THE   ORBITAL   MUSCLES.  453 

an  important  bearing  on  the  occurrence  of  associated  paralyses 
of  these  nerves. 

Hemiplegia  due  to  a  lesion  of  the  cortical  motor  region, 
which  might  happen  to  be  combined  with  paralysis  of  the  sixth 
nerve  as  a  distant  symptom,  offers  no  difficulty  in  its  diagnosis 
from  hemiplegia  with  sixth-nerve  paralysis  in  pontine  disease  ; 
for,  while  the  latter  is  a  crossed  paralysis,  the  former  is  homony- 
mous. 

Convergent  Concomitant  Strabismus. — This  is  the  condition 
which  is  popularly  known  as  inward  "cast"  or  "squint."  It 
makes  its  appearance  in  children  when  they  begin  to  take 
an  interest  in  small  objects,  such  as  toys  and  pictures,  or  a  little 
later,  when  the  first  lessons  are  learned ;  in  short,  when  they 
begin  to  make  frequent  and  prolonged  demands  on  their  internal 
recti  and  accommodation,  most  commonly  from  the  age  of  three 
to  six  years. 

The  term  "concomitant"  {concomitatus,  accompanied)  is  given 
to  it  in  contradistinction  to  "  paralytic  "  strabismus,  because  in 
it  the  squinting  eye,  by  virtue  of  the  normal  innervation  of  the 
associated  muscles,  accompanies  the  straight  one  in  all  its  move- 
ments to  an  equal  extent.  At  the  primary  position  of  the  eye- 
balls, in  a  case  of  concomitant  squint,  the  parallelism  of  the 
visual  axes  is  defective,  and,  as  the  eyes  are  moved  from  side  to 
side,  the  defective  parallelism  continues  in  the  same  degree, 
neither  increasing  nor  decreasing.  Moreover,  if  the  straight  eye 
be  shaded  by  the  surgeon's  left  hand,  and  the  squinting  eye  by 
this  means  be  obliged  to  fix  the  object  of  vision — e.  g.,  the  tip 
of  the  index  finger  of  the  surgeon's  right  hand  held  up  two  or 
more  feet  distant  in  the  median  line — it  will  be  found  that  the 
straight  eye  is  now  squinting  inward.  This  deviation  of  the 
straight  eye  is  called  the  secondary  deviation,  and  in  these  cases 
of  concomitant  strabismus  it  is  equal  in  degree  to  the  primary 
deviation  of  the  squinting  eye.  Because,  the  internal  rectus  of 
the  good  eye,  being  associated  in  its  action  with  the  external  rec- 
tus of  the  squinting  eye,  when  the  latter  muscle  is  forced,  in  the 
foregoing  experiment,  to  roll  its  eye  outward  in  order  to  bring  it 


454  DISEASES   OF   THE   EYE. 

to  fixation,  the  internal  rectus  of  the  good  eye,  receiving  a  simi- 
lar nervous  impulse,  rolls  that  eye  inward  to  the  same  extent  as 
the  squinting  eye  has  been  rolled  outward  ;  and  the  good  eye 
will  therefore  present,  under  the  covering  hand,  an  internal 
strabismus  of  the  same  amount  as  that  which  had  previously 
been  present  in  the  squinting  eye.  This  is  an  important  point, 
for  it  is  an  aid  in  the  differential  diagnosis  of  this  form  of  stra- 
bismus from  the  paralytic  form,  in  which  the  secondary  deviation 
is  greater  than  the  primary  one  (see  General  Principle  No.  2, 
p.  430). 

In  order  to  decide  which  is  the  squinting  eye,  it  is  merely 
necessary  to  direct  the  patient  to  look  at  an  object  held  up  in 
the  median  line  on  a  level  with  his  eyes  and  a  few  feet  in  front 
of  him. 

In  concomitant  strabismus,  of  course,  both  eyes  never  squint 
simultaneously,  as  one  hears  it  sometimes  stated  by  parents. 

Causes. — Squint  is  never  due,  as  is  popularly  supposed,  to 
fright,  imitation,  or  naughtiness,  nor  is  it  ever  brought  on  by 
the  patient  looking  at  a  lock  of  hair  or  other  object  which  may 
happen  to  hang  very  much  to  one  side. 

Donders^  pointed  out  that  in  a  large  proportion  of  cases 
of  convergent  strabismus  the  condition  of  refraction  is  hyper- 
metropia,  and  he  drew  the  conclusion  that  hypermetropia  is 
to  be  regarded  as  the  cause  of  the  strabismus  in  the  following 
way :  It  has  been  shown  (Chap.  I,  p.  12)  that  with  each  degree 
of  normal  convergence  of  the  optic  axes  a  certain  effort  of 
accommodation  is  associated.  The  greater  the  angle  of  normal 
convergence,  the  greater  the  possible  effort  of  accommodation. 

Of  this  physiological  fact,  Donders  said,  the  hypermetrope 
often  unconsciously  takes  advantage,  and,  in  order  to  brace 
up  his  accommodation  in  an  excessive  degree  for  the  sake  of 
distinct  vision  with  one  eye,  he  increases  the  angle  of  con- 
vergence of  the  optic  axes  by  rotating  the  other  eye  (i.  Fig. 
153)  somewhat  inward.     The  angle  I'  is  thus  made  larger  than 

"  Accommodation  and  Refraction  of  the  Eye,"  p.  292. 


THE   ORBITAL   MUSCLES.  455 

the  angle  /,  and  the  effort  of  accommodation  normally  belong- 
ing to  the  angle  V  is  obtained  for  the  eye  R,  which,  consequently, 
receives  a  clearer  image  of  the  visual  object  A  on  its  retina. 
But,  inasmuch  as  all  hypermetropes  do  not  squint.  Bonders 
considered  that  there  were  contributing  circumstances  which 
caused  each  hypermetrope  to  unconsciously  decide  between 
distinct  monocular  vision  with  strabismus  and  indistinct  bin- 
ocular vision.  The  latter,  he  said,  is  likely  to  be  preferred 
if  the  condition  of  the  refraction  and  the  acuteness  of  vision  is 
the  same  in  each  eye,  while  if  the  retinal  images  differ  much. 

Fig.  153. 


by  reason  of  one  eye  being  more  ametropic  than  its  fellow,  or 
from  nebulae  of  cornea,  or  from  other  causes,  the  desire  for 
binocular  vision  would  be  less  strong,  and  the  imperfect  eye 
would  deviate  inward  for  the  sake  of  the  resulting  increase 
of  accommodation  in  the  perfect  eye. 

It  is   admitted   on   all   hands   that  hypermetropia  is  one  of 
the   causes    of   internal   strabismus,  but,   as   Schweigger*  has 

*"Ueber  das  Schielen,"  (Berlin,  1881),  and  "  Handbuch  der  Augen- 
heilkunde,"  5th  ed.,  p.  146. 


456  DISEASES   OF   THE   EYE. 

pointed  out,  it  is  not  the  only  cause,  and,  probably,  not 
even  the  principal  cause,  for  the  following  reasons:  1.  If 
Donders'  theory  be  complete,  convergent  strabismus  must 
always  appear,  whenever  there  is  binocular  hypermetropia, 
along  with  the  conditions  which  reduce  the  value  of  binocular 
vision.  But  strabismus  is  often  absent  while  the  degree  of 
ametropia  is  markedly  different  in  the  two  eyes,  or  while  the 
acuteuess  of  vision  is  very  defective  in  one  eye.  2.  According 
to  Donders'  theory,  the  higher  the  degree  of  the  hyper- 
metropia, the  greater  should  be  the  tendency  to  strabismus; 
and  yet,  clinical  observation  shows  that  this  is  not  the  case. 
3.  In  periodical  strabismus  the  influence  of  hypermetropia 
and  of  the  accommodative  ejffort  is  very  evident,  and  yet  these 
cases  only  go  to  show  that  while  hypermetropia  is  very  fre- 
quently one  of  the  causes  of  strabismus,  it  is  not  the  only  or 
most  important  one,  for  here,  clearly,  some  factor  necessary 
for  the  production  of  a  permanent  squint  is  wanting  4.  Don- 
ders' theory  fails  to  explain  the  occurrence  of  convergent 
strabismus  in  emmetropic  and  in  myopic  individuals,  where,  of 
course,  no  excessive  efibrt  of  accommodation  is  required. 

Schweigger  considers  that  a  want  of  equilibrium  between  the 
muscles  is  the  chief  cause  of  strabismus  (divergent  as  well  as 
convergent),  and  that  convergent  strabismus  is  mainly  due  to  a 
preponderance  in  the  power  of  the  internal  over  the  external 
recti;  or,  with  equal  accuracy  one  might  say,  to  an  insufficiency 
of  the  external  recti.  It  would  seem  that,  in  hypermetropia, 
the  external  recti  are  apt  to  be  congenitally  less  powerful 
than  the  internal  recti,  while  in  myopia  congenital  insufficiency 
of  the  internal  recti  is  the  more  common  condition.  The  in- 
ternal recti  do,  however,  sometimes  preponderate  in  emme- 
tropia  and  even  in  myopia,  and,  therefore,  convergent  stra- 
bismus does  sometimes  occur  in  these  forms  of  refraction. 
Whatever  be  the  condition  of  refraction,  strabismus  is  more 
apt  to  be  developed  if  the  value  of  binocular  vision  be  dimin- 
ished by  imperfect  sight  in  one  eye. 

Spontaneous  cure  of  strabismus  does  sometimes  take   place, 


THE   ORBITAL   MUSCLES.  457 

most  commonly  between  the  tenth  and  sixteenth  year  of  age. 
That  it  may  happen  with  hypermetropia  and  with  defective 
vision  in  one  eye,  is  strongly  against  Bonders'  theory. 

According  to  Hansen  Grut's  view,*  convergent  squint  origi- 
nates in,  and  is  maintained  as  the  result  of,  an  innervation 
which  induces  in  the  interni  a  shortening  exceeding  in  amount 
that  which  is  desirable. 

Single  Vision  in  Concomitant  Convergent  Strabismus. — For 
the  most  part,  these  patients  do  not  complain  of  double  vision, 
although  diplopia  is  the  rule  in  cases  of  convergent  strabismus 
due  to  paralysis  of  the  external  rectus.  Why  is  this  ?  The 
image  of  the  object  looked  at,  it  will  correctly  be  said,  must 
be  formed  in  the  squinting  eye  in  each  of  these  kinds  of 
strabismus,  on  a  part  of  the  retina  not  identical  with  that  in 
the  fixing  eye,  but  lying  to  the  inside  of  it ;  and,  hence,  the 
image  of  the  object  should  be  projected  by  the  squinting  eye  to 
its  own  side  of  the  true  position  of  the  object  (homonymous 
diplopia),  and  the  latter  should  therefore  be  seen  doubled.  It 
is  seen  doubled  in  the  paralytic  form ;  why  not  also  in  the  con- 
comitant form?  The  only  explanation  of  this  circumstance 
which  had  been,  until  within  the  last  few  years,  put  forward 
was,  that  convergent  concomitant  strabismus  being  a  quasi- 
physiological  condition,  the  patient's  mind  involuntarily  sup- 
presses the  annoying  image  belonging  to  the  squinting  eye, 
in  a  manner  analogous  to  that  by  which,  when  we  are  deeply 
interested  in  conversation,  all  extraneous  sounds  are  unper- 
ceived,  although  they,  too,  must  reach  the  nerve  of  hearing. 
This  suppression  of  the  image  belonging  to  the  squinting  eye 
was  believed  to  be  the  more  easy  owing  to  the  indistinctness 
of  the  image  itself,  formed  as  it  is  on  a  peripheral  part  of  the 
retina,  while  in  the  good  eye  it  falls  on  the  macula  lutea. 
We  often  find,  moreover,  that  the  squinting  eye  is  ab  initio 
more  defective  (macula  cornea,  higher  degree  of  hypermetropia, 
astigmatism,  etc.)  than  its  fellow,  and  it  was  held  that  this,  too, 

*"  Bowman  Lecture,"  1889. 
39 


468  DISEASES   OF   THE   EYE. 

rendered  suppression  of  its  image  more  easy.  Such  a  suppres- 
sion of  the  image  is  possible,  and  it  no  doubt  does  occur  in  many- 
cases  of  strabismus,  but  it  is  certain,  as  pointed  out  by 
Schweigger,  that  it  does  not  occur  in  all  of  them,  perhaps  not 
even  in  most  of  them.  It  would  be  beyond  the  scope  of  this 
handbook  were  I  to  go  into  the  argumeuts  on  this  point. 
Suffice  it  to  say,  that  in  those  cases  where  suppression  of  the 
image  of  the  squinting  eye  does  not  take  place,  a  certain  partici- 
pation in  the  act  of  vision  on  the  part  of  this  eye,  when  not  too 
blind,  is  implied.  One  of  two  events  takes  place  in  those 
cases:  Either  the  region  of  the  retina,  on  which,  in  the  squint- 
ing eye,  the  image  of  the  visual  object  is  formed,  becomes  func- 
tionally developed  into  a  spot  to  a  great  extent  physiologically 
"identical  "  with  the  macula  lutea  of  the  straight  eye,  and  then 
something  approaching  normal  binocular  fusion  of  the  images 
comes  about,  and  hence  single  vision ;  or  else  diplopia  is  actu- 
ally present,  although,  as  a  rule,  it  passes  unnoticed  by  the 
patient,  owing  to  its  having  become  habitual  to  him.  In  some 
cases  the  first  of  these  conditions  is  the  actual  state,  in  others  it 
is  the  second  which  exists.  I  shall  mention  one  fact  in  support 
of  each,  but  must  refrain  from  entering  more  deeply  into  the 
subject.  In  support  of  the  first  is  the  occurrence,  not  rarely 
observed,  of  crossed  diplopia  after  operation  for  concomitant 
convergent  strabismus  ;  and  in  support  of  the  second,  the  diplopia 
which  intelligent  patients  often  admit  when  they  are  carefully 
examined  with  the  aid  of  a  red  glass  before  the  good  eye. 

Amblyopia  of  the  Squinting  Eye. — In  a  large  proportion  of 
the  cases  of  internal  concomitant  strabismus  the  squinting 
eye — even  where  there  is  no  marked  astigmatism,  and  where 
the  media  are  clear — is  amblyopic.  Schweigger  states  the  pro- 
portion of  these  amblyopic  cases  to  be  thirty  per  cent.,  but  I 
believe  the  percentage  to  be  much  larger.  It  has  been  a  very 
generally  accepted  opinion  that  this  amblyopia  is  due  to  want  of 
use  on  the  part  of  the  squinting  eye,  in  consequence  of  the  sup- 
pression of  the  image  on  its  retina,  and,  hence,  it  is  termed 
amblyopia  ex  anopsia.     If  this  view  were  the  correct   one,  we 


THE   ORBITAL   MUSCLES.  459 

ought  always  to  find  only  slight  amblyopia  of  the  squinting  eye 
in  children  soon  after  strabismus  comes  on,  while  it  should  be  of 
high  degree — in  fact,  the  eye  should  be  almost  useless — in  adults 
who  have  not  been  operated  on  and  in  whom  raonolateral  strabis- 
mus had  been  present  since  childhood.  And  yet  marked  ambly- 
opia may  often  be  found  in  children  in  the  squinting  eye,  while 
in  adults  the  squinting  eye  often  has  very  good  vision — in  short, 
the  amblyopia  of  the  squinting  eye  is  not  progressive,  as  it  would 
be  were  it  ex  anopsia.  Again,  many  squinting  eyes,  when  the 
straight  eye  is  covered,  instead  of  fixing  the  visual  object  with  the 
macula  lutea,  remain  unchanged  in  position,  or  even  turn  inward 
more  than  before — (amblyopia  with  eccentric  fixation) — and,  in 
less  well-marked  cases  of  the  same  sort,  although  there  is  no 
eccentric  fixation,  yet  the  preference  for  fixation  with  the 
macula  lutea  is  lost,  and  uncertainty  of  fixation  results,  no 
one  part  of  the  retina  being  more  useful  for  that  purpose 
than  another.  It  is  held  by  many  that  this  form  is  character- 
istic of  amblyopia  ex  anopsia,  and  is  the  result  of  the  strabis- 
mus; but  it  is  identical  with  a  form  of  congenital  amblyopia 
often  present  in  only  one  eye  without  strabismus  (p.  417).  A 
strong  argument  in  favor  of  amblyopia  ex  anopsia  is  the  im- 
provement which  often  seems  to  take  place  in  the  vision  of  the 
squinting  eye  by  systematic  separate  use,  or  after  the  strabotomy. 
But  it  is  tolerably  certain  that  where  the  improvement  takes 
place,  the  defective  vision  has  been  due  rather  to  retinal  asthe- 
nopia than  to  amblyopia ;  and  if,  at  the  outset,  patients  be 
pressed  to  discern  the  test-types,  they  often  succeed  in  producing 
a  better  acuteness  of  vision  than  they  at  first  seemed  to  possess. 
In  many  cases  separate  use  fails  altogether  in  improving  the 
vision  of  the  squinting  eye,  even  when  it  is  not  very  defective, 
a  fact  which  is  unfavorable  to  the  amblyopia  ex  anopsia 
theory.  The  circumstance  that  in  alternating  strabismus  the 
sight  of  each  eye  is  good  cannot  be  regarded  as  proof  in 
favor  of  amblyopia  ex  anopsia  rather  than  against  it. 

The  explanation  which  Schweigger  gives  of  the  very  frequent 
presence  of  amblyopia  in  the  squinting  eye  is  that  it  is  cougen- 


460 


DISEASES   OF   THE    EYE. 


Fig.  154. 


ital,  and,  far  from  being  the  result  of  the  strabismus,  is  a  factor 
in  its  production,  just  as  opacities  of  the  cornea  or  high  degrees 
of  ametropia  have  always  been  admitted  to  be. 

There  are  Three  Clinical  Varieties  of  Convergent  Concomitant 
Strabismus. — 1.  Periodic.  2.  Permanent  alternating.  3. 
Permanent  monolateral.  Periodic  strabismus  occurs  only  when 
some  great  effort  of  accommodation  is  required.  It  sometimes 
is  the  first  stage  of  permanent  monolateral  or  of  alternating  stra- 
bismus ;  but  these  two  latter  forms  do  not  always  have  their  be- 
ginning in  the  periodic  form,  which  often  continues  as  periodic 
to  the  end  of  the  chapter.  In  alternating  strabismus  the  patient 
squints  sometimes  with  one  eye  and  some- 
times with  the  other.  In  permanent 
monolateral  strabismus  the  squint  is  con- 
fined to  one  eye. 

Measurement  of  Convergent  Strabismus. 
— The  amount,  or  degree,  of  the  devia- 
tion of  the  squinting  eye  from  its  normal 
position  is  not  the  same  in  every  case, 
and  the  size  of  the  squint  is  measured  by 
one  of  the  following  methods.  Which- 
ever of  them  be  used,  it  is  important  that 
the  patient  be  directed,  during  the  test,  to 
regard  a  distant  object  placed  in  the 
median  line  and  on  a  level  with  his  eyes. 
If  he  look  at  a  near  object,  the  squint 
may  be  over-estimated,  by  reason  of  its 
increase  with  accommodation. 

1.  By  the  Linear  Method  we  measure 
the  number  of  millimetres  by  which  the 
eye  deviates  from  its  normal  position. 
The  good  eye  is  shaded,  and  the  squinting 
eye  is  caused  to  fix  an  object  in  the 
median  line — by  preference  a  distant  ob- 
ject. Close  under  the  margin  of  the  lid  a  strabometer  (Fig. 
154)  is   then  placed,  so  that  the  0  point  may  coincide  with  a 


THE    ORBITAL   MUSCLES. 


461 


perpendicular  let  fall  from  the  centre  of  the  cornea.  The  shade 
being  removed  from  the  good  eye,  the  squinting  eye  is  allowed 
to  resume  its  abnormal  position,  and  the  degrees  recorded  on  the 
instrument,  under  a  perpendicular  let  fall  from  the  centre 
of  the  cornea  in  this  position,  are  read  off.  They  give  the 
amount  of  the  deviation. 

2.  Hirschberg's  Method*  consists  in  estimating  the  degree  of 
deviation  by  the  position  of  the  corneal  reflex  of  a  candle  flame 
held  straight  in  front  of,  and  about  a  foot  from,  the  eye.  Where 
there  is  no  squint,  this  reflex  is  situated  at,  or  (with  large 
angle  y)  slightly  to  the  inner  side  of,  the  centre  of  the  pupil  in  each 

Fig.  155. 


ntedium  f^mlTij jjimil 


-mnrf/u/  of' 
coriif  fi 


eye.  In  a  convergent  squinting  eye  it  is  displaced  outward, 
and  Hirschberg  recognizes  five  groups  of  strabismus.  Group  1 
(Fig.  155,  representing  the  right  eye),  in  which  the  reflex  is 
nearer  to  the  centre  than  to  the  margin  of  the  pupil.  This 
represents  a  strabismus  of  less  than  10°,  and  no  operation  is 
indicated.  Group  2,  in  which  the  reflex  is  at  or  about  the 
margin  of  the  pupil ;  representing  a  strabismus  of  12°  to  15°, 
and  indicating  a  simple  tenotomy,  with  occasionally  a  tenotomy 
of  the  other  int.  rectus.  Group  3,  in  which  the  reflex  is  outside 
the  pupillary  margin,  about  half-way  between  the  centre  of  the 
pupil  and  the  corneal  margin.  This  represents  a  strabismus  of 
about  25°,  and  indicates  a  tenotomy  of  the  internal  rectus,  com- 


Centralhlatt  f.  p.  Augenheilkunde,  1886,  p.  5. 


462  DISEASES   OF   THE   EYE. 

bined  with  a  moderate  advancement  of  the  external  rectus. 
Occasionally,  later  on,  a  tenotomy  of  the  other  internal  rectus 
will  be  required.  Group  4,  in  which  the  reflex  is  on  or  near 
the  corneal  margin ;  representing  a  strabismus  of  45°  to  50°, 
and  indicating  a  tenotomy  of  the  internal  rectus,  along  with 
energetic  advancement  of  the  external  rectus,  and  sometimes  a 
later  tenotomy  of  the  other  internal  rectus.  Group  5,  in  which 
the  reflex  is  on  the  sclerotic,  between  the  margin  of  the  cornea 
and  the  equator  bulbi.  This  represents  a  strabismus  of  60°  to 
80°,  and  requires  the  combined  operation,  with  strongest  pos- 
sible advancement  of  the  externus.  Even  this  is  sometimes 
insuflicient,  and  a  tenotomy  of  the  internal  rectus,  or  even  the 
combined  operation  on  the  other  eye,  may  be  subsequently 
required.  This  is  a  modification  of  the  linear  method,  and  is  a 
convenient  one  in  routine  practice. 

3.  Priestley  Smith  measures  strabismus  by  means  of  a  double 
tape,  used  in  conjunction  with  the  ophthalmoscope,  as  shown  in 
the  accompanying  figures.  The  patient  places  the  ring  P  on 
one  of  his  fingers,  and  holds  it  to  his  cheek.  The  observer 
places  the  ring  0  on  the  forefinger  of  the  hand  which 
holds  the  ophthalmoscope  ;  this  keeps  his  eye  at  a  distance  of 
one  metre  from  the  patient's  face.  He  uses  his  disengaged 
hand  as  a  fixation  object  for  the  patient,  holding  it  edgewise 
toward  the  patient,  and  letting  the  graduated  tape  slide 
between  his  fingers.  A  small  weight  at  the  end  of  the  tape 
keeps  it  stretched  as  the  hand  moves  in  either  direction. 

Fig.  157  illustrates  the  measurement  of  a  convergent  strabis- 
mus of  the  right  eye.  The  patient,  seated  below  the  lamp  and 
holding  the  tape  as  above  described,  is  told  to  look  at  the 
mirror.  The  observer,  holding  the  ring  0  and  the  mirror  in 
the  right  hand,  throws  the  light  on  the  patient's  left  eye  (X), 
I.  e.,  the  fixing  eye.  He  sees  the  corneal  reflex  in  the  centre  of 
the  pupil,  and  knows  thereby  that  this  eye  is  fixing  properly. 
He  then  throws  the  light  on  the  right  eye  (i?),  and  sees  the 
reflex  situated  eccentrically  outward,  and  knows  that  this 
eye   deviates   inward.      Taking    the    graduated    tape   between 


THE   ORBITAL   MUSCLES. 


463 


the  fingers  of  his  left  hand,  and  telling  the  patient  to  watch 
this  hand,  he  moves  it  outward  along  the  tape  (see  Fig. 
156),  and  meanwhile  watches  the  corneal  reflex  in  the 
deviating  eye.     When   this    latter   reaches   the    middle  of  the 


Fig.  156. 


P  O 


pupil,  he  reads  the  position  of  the  hand  upon  the  tape.  The 
axis  of  the  deviating  eye  (i?)  has  moved  from  R'  to  0,  through 
the  angle  R'  R  0.  The  axis  of  the  non-deviating  eye  (X)  has 
moved  through  an  equal  angle,  0  L  U.  The  angular  movement 
of  X,as  measured  by  the  tape,  equals  the  angular  deviation  ofi?. 


464 


DISEASES   OF   THE    EYE. 


Fig.  158  illustrates  the  measurement  of  a  divergent  strabismus 
of  the  right  eye.  The  hands  must  be  reversed,  but  the  principle 
is  the  same  as  before. 

The  graduated  tape  is  a  substitute  for  a  graduated  arc  of  a 
circle,  but  does  not  exactly  correspond  with  such  an  arc ;  the 
error  involved  is,  however,  so  small  as  to  be  of  no  importance, 
if  the  observer  keep  his  two  hands  at  about  the  same  distance 

Fig.  159. 


from  the  patient's  face.  In  this  mode  of  measuring  a  strabismus 
it  is  the  excursion  of  the  fixing  eye  which  is  actually  measured, 
and  the  excursion  of  the  deviating  eye  is  supposed  to  be  equal  to 
it.  If  the  excursions  of  the  two  eyes  are  unequal,  the  result 
would  be  at  fault.  The  method,  though  difficult  to  explain  in 
words,  is  very  quick  and  satisfactory  in  practice. 

4.  The  Angular  Method. — The  object  aimed  at  here  is  to  de- 


THE    ORBITAL   MUSCLES.  465 

termine  the  size  of  the  angle  which  the  visual  axis  of  the 
squinting  eye  makes,  with  the  direction  it  should  normally  have. 
For  this  purpose  a  perimeter  is  employed.  Let  us  suppose  that 
the  right  eye  (B,  Fig.  159)  be  the  squinting  eye,  and  that  P  o  P 
be  the  arc  of  the  perimeter.  The  patient  is  placed  at  the  instru- 
ment, as  though  the  field  of  vision  of  his  squinting  eye  were 
about  to  be  examined.  He  is  directed  to  look  at  a  distant 
object  (A)  with  his  good  eye  {L).  The  visual  line  from  P  should 
now  pass  through  the  point  o,  but  it  passes  through  the  point  n, 
and  therefore  o  P  n  is  the  angle  of  the  strabismus.  The  surgeon 
finds  the  position  of  n  by  carrying  the  flame  of  a  candle  along 
the  perimeter,  until,  with  his  eye  placed  behind  the  flame,  he 
finds  that  the  corneal  image  of  the  flame  occupies  the  centre  of 
the  pupil.  The  flame  itself  will  then  be  at  n,  and  the  size  of  the 
squint-angle  may  be  read  oflf  there.  This  gives  us  the  optical 
axis  of  the  eye;  but,  to  be  strictly  accurate,  we  must  remember 
that  the  position  of  the  visual  axis  is  what  we  require,  and  that 
it  lies  a  few  degrees  further  inward,  according  to  the  size  of  the 
angle  y.  The  angular  method  is  now  in  general  use  instead  of 
the  linear  method,  than  which  it  is  more  accurate. 

5.  A  good  subjective  method  for  determining  the  dimension 
of  a  strabismus,  but  which  can  only  be  used  where  diplopia  is 
present,  is  what  may  be  called  the  Method  by  Tangents.  Upon 
a  wall  of  the  consulting-room,  in  a  horizontal  line,  and  so  as  to 
be  on  a  level  with  the  eyes  of  the  patient,  who  is  placed  about 
three  metres  from  the  wall,  are,  permanently  marked  out, 
tangents  of  angles  of  5°  each,  as  seen  from  the  place  where  the 
squinting  eye  is.  Exactly  opposite  to  the  squinting  eye  is  0°, 
while  toward  the  right  and  left  the  points  are  marked  up  to  45° 
or  more.  The  flame  of  a  candle  being  held  at  0°,  and  one  eye 
of  the  patient  being  covered  with  a  red  glass,  he  is  called  on  to 
indicate  the  position  of  the  image  belonging  to  the  squinting 
eye,  and  the  number  on  the  wall  which  corresponds  to  this  gives 
the  angle  of  the  strabismus.  For  the  purpose  of  estimating 
paralyses  of  the  orbital  muscles,  a  similar  row  of  tangents,  or 
several  such,  may  be  marked  out  in  the  vertical  direction.     Xo 


466  DISEASES   OF   THE   EYE. 

well-ordered  ophthalmic  institution  should  be  without  this  simple 
arrangement. 

Mohility  of  the  Eye  Outward  in  Convergent  Concomitant  Stra- 
bismus.— This  is  often  defective  in  the  squinting  eye,  and  some- 
times also  in  the  fixing  eye.  The  excursiveness  of  the  lateral 
motions  of  the  eyeball  may  be  measured  by  the  perimeter. 
Placing  the  patient  as  though  the  field  of  vision,  say  of  his  right 
eye,  were  about  to  be  examined,  the  patient  is  directed  to  follow 
with  his  eye  the  flame  of  a  candle  carried  along  the  perimeter 
from  0°  toward  90°  in  the  temporal  direction,  and  when  it  is 
found  that  the  eye  cannot  be  turned  any  further  in  this  direction, 
the  extreme  position  is  noted  by  the  position  of  the  candle  at 
the  perimeter.  The  corneal  image  of  the  flame  must,  of  course, 
be  central  when  the  position  of  the  flame  is  read  ofi*.  In  a 
similar  way,  the  mobility  of  the  eye  inward  may  be  measured. 
In  the  normal  eye  the  mobility  in  each  direction  is  about  45°. 
In  strabismus  we  simply  compare  the  outward  mobility  of  the 
squinting  eye  with  that  of  the  good  eye,  to  ascertain  how  much, 
if  anything,  the  former  lacks  of  its  normal  amount. 

Treatment. — The  bearing  of  hypermetropia  on  the  production 
of  many  cases  of  strabismus  long  since  suggested  the  idea  of 
curing  the  deviation  by  spectacles  which  would  correct  any 
existing  hypermetropia.  The  accommodation  having  been  para- 
lyzed by  atropine,  is  kept  under  its  influence  for  some  weeks  or 
months";  spectacles  which  completely  correct  the  hypermetropia 
and  astigmatism  being  meantime  constantly  worn.  Should  the 
patient  require  to  use  his  eyes  for  near  work  while  under  treat- 
ment, it  is  necessary  that  he  should  have  suitably  higher  -|- 
glasses  for  his  near  work.  Occasionally,  good  cures  are  effected 
by  this  means;  and,  when  a  periodic  strabismus  in  a  child  comes 
under  my  care,  I  always  think  it  worth  while  to  attempt  its  cor- 
rection in  this  way ;  but,  in  general,  it  is,  by  itself,  of  no  use 
whatever. 

Orthoptic  Treatment. — To  Javal  *  is  due  the  credit  of  devising 

*  Ajinales  d' Oculist i que,  Juillet  et  Aodt,  1871.  See  also  Mars  et 
Avril,  Mai  et  Juin,  and  Nov.  et  Dec,  for  the  same  year. 


THE    ORBITAL    MUSCLES.  467 

this  method ;  but,  although  he  did  so  some  years  ago,  it  is  only 
recently  that  the  treatment  has  been  introduced  into  practical 
ophthalmology. 

In  order  that  the  treatment  may  be  carried  out,  it  is  necessary, 
in  the  first  instance,  that  the  strabismic  person  should  have 
diplopia.  If  the  latter  be  not  present  spontaneously,  it  has  to 
be  developed ;  and  it  is  sometimes  possible,  when  the  sight  in 
the  squinting  eye  is  not  too  defective,  to  give  the  patient  diplopia, 
i.  e.,  to  make  him  continuously  conscious  of  the  presence  of  the 
image  belonging  to  the  squinting  eye.  This  may  be  done  by  means 
of  exercises  with  a  prism,  base  downward,  before  the  deviated 
eye,  and  a  candle  flame  as  visual  object.  The  exercises  are  to 
be  repeated  daily  until  diplopia  without  a  prism  is  established. 
Javal  recommends  the  following  exercise  to  develop  diplopia : 
A  screen — e.  g.,  a  large  sheet  of  cardboard — is  held  vertically 
between  the  two  eyes,  while  the  patient  is  directed  to  look  at  a 
candle  flame  about  two  metres  in  front  of  him.  Double  vision 
may  immediately  appear ;  but,  if  it  does  not,  it  may  be  brought 
out  by  now  and  then  covering  the  good  eye  for  a  moment,  or  by 
placing  before  it  a  red  glass,  which  can  soon  be  done  without. 
Less  brilliant  visual  objects  are  gradually  substituted,  until, 
finally,  the  double  vision  will  continue  even  when,  at  first 
cautiously,  the  screen  is  removed. 

Double  vision  having  been  established,  we  proceed  to  enable 
the  patient  to  fuse  the  double  images,  i.  e.,  to  obtain  binocular 
vision,  and  when  we  have  succeeded  in  doing  this,  we  have 
cured  the  squint.  The  end  in  view  is  best  efiected  by  means  of 
a  stereoscope,  into  which,  in  place  of  the  usual  prisms,  -|-  6  D 
lenses  have  been  introduced.  The  focal  distance  of  these  lenses 
being  about  the  length  of  an  ordinary  stereoscope,  rays  coming 
from  the  slides,  and  passing  through  them,  fall  into  the  observer's 
eye  as  parallel  rays,  the  accommodation,  consequently,  is  sus- 
pended, and,  under  normal  conditions,  the  visual  lines  are 
parallel,  as  though  looking  at  a  distant  object.  In  the  normal 
state  the  double  picture,  or  diagram,  will  seem  to  be  single,  but 
to  the  strabismic  patient  in  whom  diplopia  is  present  it  will  be 


468  DISEASES    OF    THE    EYE. 

double.  Our  duty,  then,  is  to  diminish  the  distance  between  the 
pictures,  until  the  patient  finds  himself  just  able  to  fuse  the 
images  into  a  single  impression.  After  a  day  or  two  the  distance 
is  increased  slightly,  and  so  on,  until,  finally,  the  normal  position 
is  reached.  It  is  needless  to  say  that  in  these  exercises  all  errors 
of  refraction  must  be  eliminated  by  the  proper  glasses."^' 

The  pictures  used  in  the  stereoscope  should  be  geometrical 
figures,  or  specially  designed  pictures,  in  order  that  both  surgeon 
and  patient  may  the  more  readily  recognize  their  fusion. 

Only  the  very  slight  degrees  of  strabismus  are  adapted  for  the 
attempt  at  cure  by  orthoptic  treatment.  A  marked  deviation 
will  not  be  amenable  to  it.  Moreover,  it  makes  demands  both 
upon  the  patience  and  intelligence  of  the  patient,  which  are 

*The  existence,  or  otherwise,  of  true  binocular  vision  may  be  ascer- 
tained by  the  simple  experiment  of  giving  the  patient  a  book  to  read, 
and  holding  a  cedar  pencil  half-way  between  his  eyes  and  the  page, 
perpendicularly  to  the  lines  of  type.  If  binocular  vision  be  present,  the 
pencil  will  not  offer  any  impediment  to  the  reading  ;  but,  if  it  be  not 
present,  parts  of  the  page  will  be  hidden  behind  the  pencil.  The  surgeon 
may  prove  this  by  performing  the  experiment  on  himself,  first  with  both 
eyes  open  (binocular  vision),  and  then  with  one  eye  shut. 

Another  method  is  that  known  as  Bering's  Drop  Experiment.  A 
cylinder  about  25  cm.  long,  and  wide  enough  to  take  in  both  eyes  of  a 
person,  is  arranged,  at  the  opposite  end  from  that  placed  around  the 
eyes,  with  two  strong  wires  18  inches  long,  which  jut  out  in  continuation, 
as  it  were,  of  the  cylinder,  but  which  are  bent  outward  sufficiently  to  keep 
them  out  of  view  of  the  patient.  Between  the  ends  of  these  wires  a  fine 
thread  is  stretched,  with  a  small  bead  fastened  at  its  middle  point,  so 
that  the  bead  may  occupy  the  centre  of  the  field  when  the  patient  looks 
through  the  cylinder.  During  the  experiment  the  thread  is  in  the  hori- 
zontal position,  and  the  bead  is  used  as  the  patient's  fixation  point. 
Small  balls  of  different  sizes  (peas,  beans,  etc  )  are  then  let  fall  from  a 
height,  one  after  another,  a  couple  of  dozen  times  or  more,  some  of  them 
in  front  of  the  thread,  some  of  them  behind  it.  If  the  patient  have 
normal  binocular  vision,  he  will  be  able  to  say  each  time  with  certainty 
whether  the  ball  falls  in  front  of  or  behind  the  thread  ;  but,  if  he  have 
not  true  binocular  vision,  if  only  one  eye  be  used,  he  will  merely  guess 
at  the  position  of  the  falling  ball,  and  will  make  frequent  mistakes. 


THE    ORBITAL    MUSCLES.  469 

rarely  fulfilled,  especially  in  hospital  practice.  A  field  more 
fertile  in  good  results  for  this  treatment  is  found  in  the  com- 
pletion of  cures  which  have  been  commenced  by  operative 
measures. 

Operative  Treatment. — Division  of  the  tendon  of  the  internal 
rectus  muscle,  combined,  sometimes,  with  advancement  of  the 
insertion  of  the  external  rectus,  is  the  measure  which  has  to 
be  applied  in  most  of  the  cases  which  come  under  our  notice. 
I  am  strongly  opposed  to  operative  interference  in  patients 
under  five  years  of  age,  and  very  much  prefer  that  they 
should  be  seven  or  eight  years  old,  or  even  older.  Early 
childhood  ofl?ers  a  decided  obstacle  to  the  careful  adjustment 
of  the  operation  and  to  orthoptic  treatment. 

In  order  that  the  operative  proceeding  may  be  adapted  to 
each  case,  the  following  points  must  have  been  previously  noted 
with  care :  a.  The  dimension  of  the  strabismus  angle,  h.  The 
lateral  mobility  of  the  eyes,  especially  the  mobility  outward 
of  the  squinting  eye.  c.  The  refraction  of  the  eyes  and  the 
acuteness  of  vision  of  the  squinting  eye,  as  well  as  the  presence 
or  otherwise  of  diplopia :  The  first,  in  order  that  glasses  for 
the  correction  of  any  hypermetropia  may  be  worn  if  desirable 
after  the  operation  ;  the  second,  because,  ceteris  jmrihiis,  an 
operation  for  convergent  strabismus  will  produce  a  more 
marked  effect  if  the  vision  in  the  squinting  eye  be  good  than 
if  it  be  very  defective ;  and  the  third,  because  the  presence 
of  diplopia  encourages  the  hope  that  binocular  vision  may- 
be restored. 

Kules  which  will  ensure  in  every  case,  with  absolute 
certainty,  the  desired  degree  of  operative  effect  cannot  be 
laid  down.  The  following  will  be  found  to  answer  in  the 
majority  of  cases,  and,  if  the  effect  be  now  and  then  too  great, 
it  can  easily  be  adjusted  by  bringing  forward  the  internal 
rectus,  or  by  setting  back  the  external  rectus,  within  a  few 
days  after  the  operation.  In  every  instance  it  should  be  the 
desire  of  the  surgeon  to  leave  2°  or  3°  of  strabismus  behind  ; 


470  DISEASES   OF   THE   EYE. 

for  the  effect  of  the  operation  is  apt  to  increase  within  a  year, 
and,  if  absolute  parallelism  be  present  at  first,  divergence  may 
ultimately  supervene.  The  establishment  of  binocular  vision, 
when  possible,  would  do  away  with  this  remnant  of  strabismus ; 
but,  under  any  circumstances,  the  latter  does  not  detract  from 
the  cosmetic  result. 

If  the  vision  of  the  squinting  eye  be  fairly  good,  and  the 
deviation  amount  to  not  more  than  15°  or  20°,  and  the  power 
of  the  external  rectus  be  sufficient,  the  correction  can  be  effected 
by  the  tenotomy  of  the  internal  rectus  of  the  squinting  eye. 
A  strabismus  of  20°  will  require  the  free  separation  of  the 
delicate  connections  between  the  anterior  surface  of  the 
tendon,  or  capsule  of  Tenon,  and  the  conjunctiva  as  far  back 
as  the  caruncle,  in  order  that  the  tendon  may  be  free  to 
contract.  For  a  deviation  of  15°  or  less  this  separation  should 
not  be  so  free,  or  should  be  quite  omitted  ;  or,  if  a  very  slight 
effect  be  desired,  it  can  be  produced  by  drawing  the  conjunc- 
tival wound  together  after  an  operation  which  has  been  confined 
strictly  to  the  insertion  of  the  tendon. 

If  the  vision  of  the  squinting  eye  be  fairly  good,  and  the 
power  of  the  external  rectus  sufficient,  and  if  the  squint  be 
more  than  20°,  it  is  advisable  to  divide  the  proceeding  between 
the  eyes,  e.  g.,  if  it  be  30°,  about  20°  are  corrected  by  tenotomy 
of  the  internal  rectus  of  the  squinting  eye  and  the  remainder 
by  tenotomy  of  the  internal  rectus  of  the  fixing  eye.  If  desired, 
the  effect  of  the  tenotomy  in  one  or  both  eyes  may  be  increased 
by  a  suture  passed  through  a  fold  of  conjunctiva  at  the  outer 
side  of  the  globe,  and  tied  tightly. 

If,  although  the  vision  of  the  squinting  eye  be  good,  and 
the  deviation  not  more  than  20°  or  25°,  there  be  marked  loss 
of  power  of  the  external  rectus  muscle,  tenotomy  of  the  internal 
rectus  alone  will  often  lead  to  disappointment,  and  a  good 
result  will  require  this  tenotomy  to  be  combined  with  advance- 
ment of  the  external  rectus;  the  operative  measures  being 
confined  to  the  squinting  eye.     But  advancements  in  such  cases 


THE    ORBITAL    MUSCLES.  471 

as  this  must  be  very  cautiously  carried  out,  as  an  excessive  effect 
may  easily  be  produced.  The  external  rectus  should  be  but 
slightly  brought  forward. 

If  the  deviation  exceeds  35°,  even  when  there  is  good  vision 
in  the  squinting  eye  and  no  loss  of  power  in  the  external  rectus, 
tenotomy  of  the  internal  rectus  of  each  eye  is  rarely  sufficient, 
and,  as  a  rule,  advancement  of  the  external  rectus  of  the  squint- 
ing eye  must  be  combined  with  these  measures. 

With  a  deviation  of  30°  to  35°  and  loss  of  power  in  the  ex- 
ternal rectus,  the  demand  for  advancement  of  the  external 
rectus  becomes  more  imperative.  The  correction  of  squints  of 
40°  and  more  are,  in  every  instance,  to  be  effected  by  teno- 
tomy with  vigorous  advancement  in  the  squinting  eye,  and 
subsequent  tenotomy  of  the  internal  rectus  in  the  good  eye. 

In  cases  where  the  vision  of  the  squinting  eye  is 
much  reduced,  the  deviation  great,  and  the  insufficiency 
of  the  external  rectus  marked,  the  combined  operation  (f^^^^ 
in  one  or  both  eyes  is  the  proper  proceeding. 

Mode  of  Operating  for  Strabismus. —  Tenotomij. — The 
instruments  required  for  this  operation  are,  a  spring-stop 
speculum,  a  small-toothed  forceps,  a  blunt  scissors  some- 
what curved  on  the  flat,  and  two  strabismus  hooks  (Fig. 
160). 

The  eye  having  been  thoroughly  cocainized,  the  pa- 
tient is  placed  on  his  back,  the  surgeon  standing  in  front 
of  him  and  on  his  left-hand  side,  if  the  left  eye  is  to  be 
operated  on ;  or  behind  him,  if  it  be  the  right  eye. 
The  speculum  is  then  applied,  and  the  conjunctiva  over 
the  insertion  of  the  tendon  of  the  internal  rectus  is  seized  with 
the  forceps  and  incised  with  the  scissors  between  the  forceps 
and  the  eye.  Into  the  opening  thus  made  the  points  of  the 
closed  scissors  are  inserted,  and,  with  a  snipping  action,  a  pas- 
sage is  made  through  the  subconjunctival  tissue  ;  from  the  con- 
junctival aperture  to  the  upper  border  of  the  tendon  in  case  of 
the  left  eye,  or  to  its  lower  border  in  the  right  eye.  The  scissors 
are  now  laid  aside,  but  the  conjunctiva  is  still  held  in  the  forceps. 


472  DISEASES   OF   THE    EYE. 

aad,  with  the  right  hand,  the  point  of  the  hook  is  passed 
through  the  opening  and  along  the  passage,  until  the  edge  of 
the  tendon  is  reached.  The  point  of  the  hook  being  kept  in 
contact  with  the  sclerotic,  the  instrument  is  then  turned  rapidly 
round  and  under  the  tendon,  and  is  brought  close  up  to 
the  insertion  of  the  latter  into  the  sclerotic,  care  being  taken 
that  the  whole  breadth  of  the  tendon  lies  on  the  hook.  The  for- 
ceps are  now  laid  aside,  and  the  hook  carrying  the  tendon  is 
transferred  to  the  left  hand.  One  blade  of  the  scissors  (held  in 
the  right  hand)  is  now  inserted  between  the  globe  and  the  ten- 
don, and  the  latter  is  completely  divided  at  its  insertion.  The 
second  hook  is  then  employed  for  searching,  above  and  below, 
for  any  strands  of  the  tendon  which  may  be  left  undivided,  the 
test  for  complete  division  being  that  the  hook  can  be  brought 
up  without  obstruction  to  the  margin  of  the  cornea.  If  the 
smallest  segment  of  the  tendon  be  left  undivided,  the  result  of 
the  operation  is  apt  to  be  unsatisfactory.  Immediately  after  the 
operation  a  marked  diminution  in  the  mobility  of  the  eye  in- 
ward should  be  looked  for,  as  this  motion  can  now  only  take 
place  by  aid  of  any  remaining  connective  tissue  attachments  of 
the  muscle  to  the  eyeball  and  capsule  of  Tenon.  If  this  defect 
in  motion  be  not  present,  or  in  only  a  slight  degree  in  compari- 
son with  the  supposed  extent  of  operation,  it  may  be  concluded 
that  the  tendon  is  imperfectly  divided,  and  a  new  search  for 
undivided  filaments  must  be  made.  To  estimate  this  loss  of 
motion,  it  is  necessary  before  the  operation  to  note  the  degree  of 
mobility  of  the  eyeball  inward,  and  to  compare  it  with  the  in- 
ward motion  of  the  other  eye. 

The  effect  of  the  operation  may  be  diminished,  if  found  neces- 
sary, by  drawing  the  edges  of  the  conjunctival  wound  together 
with  a  suture,  the  tendon  being  thus  prevented  from  uniting 
with  the  globe  so  far  back.  The  more  conjunctiva  we  include 
in  the  suture  at  each  side  of  the  wound,  the  more  will  the  effect 
of  the  tenotomy  be  reduced.  This  restricting  suture  should  be 
applied  when  the  immediate  result  of  the  tenotomy  is  greater 
than  expected  or  desired. 


THE   ORBITAL   MUSCLES.  473 

As  the  edges  of  the  conjunctival  wound  cannot  be  accurately 
adjusted  with  sutures,  none  are  applied  for  that  purpose.  They 
are  only  used,  as  above,  to  diminish  the  operative  effect;  or, 
when  an  extensive  loosening  of  the  subconjunctival  tissue  has 
been  performed,  to  prevent  sinking  of  the  caruncle. 

The  Subconjunctival  Operation  for  Strabismus,  proposed  by 
the  late  Mr.  Critchett,  is  performed  as  follows :  A  fold  of  con- 
junctiva is  seized,  close  to  the  lower  margin  of  the  insertion  of 
the  muscle,  and  incised  with  a  blunt-pointed  scissors,  so  as  to 
expose  the  tendon.  A  strabismus  hook  is  passed  through  the 
opening  and  under  the  tendon.  The  scissors  is  now  inserted 
and  opened  slightly,  one  point  being  kept  close  to  the  hook  while 
the  other  is  passed  between  the  tendon  and  the  conjunctiva,  and 
the  tendon  is  divided  close  to  its  insertion.  This  method  is  very 
generally  adopted  by  English  surgeons.  For  myself,  I  prefer 
the  operation  (von  Graefe's)  previously  described,  as  it  much 
more  readily  admits  of  modifications  of  the  effect. 

In  von  Arlt's  Method,  instead  of  a  hook  being  passed  under 
the  tendon  in  the  first  instance,  it  is  seized  with  the  forceps  with 
which,  just  before,  the  conjunctiva  had  been  raised.  In  other 
respects  the  proceeding  is  the  same  as  von  Graefe's,  than  which 
it  is  said  to  be  less  painful. 

The  immediate  and  ultimate  effects  of  a  tenotomy  are  by  no 
means  identical.  Immediately  after  the  operation  the  effect  is 
very  marked,  owing  to  the  loosening  of  the  tendon  from  its 
insertion.  In  a  few  days,  when  it  becomes  re-attached,  the  effect 
diminishes,  and  in  the  course  of  some  weeks  there  is  again  an 
increase  in  the  effect,  and  this  increase  continues  for  about  a 
year,  as  above  stated. 

The  ultimate  result  may,  with  tolerable  certainty,  be  estimated 
immediately  after  the  operation,  by  testing  the  power  of  con- 
vergence. If  the  patient  be  directed  to  look  with  both  eyes  at 
the  surgeon's  finger  held  in  the  middle  line,  and  it  be  approached 
to  within  12  or  15  cm.  of  his  nose,  and  if  the  convergence  of 
the  eyes  can  be  maintained  at  that  distance,  the  effect  will  not 
be  too  great.  But  if,  at  a  distance  of  from  18  to  20  cm.,  the 
40 


474  DISEASES   OF   THE   EYE. 

operated  eye  ceases  to  converge,  or  begins  to  diverge,  or  if  even 
at  12  cm.  the  convergence,  although  accomplished,  cannot  be 
maintained  for  more  than  a  few  moments,  and  that  then  the 
operated  eye  deviates  outward,  ultimate  divergence  may  be 
expected,  even  though  the  actual  position  of  the  visual  axes  be 
correct.     A  restricting  suture  must  be  applied  in  such  cases. 

Sometimes,  although  the  patient  converges  up  to  12  cm.  satis- 
factorily, and  maintains  the  convergence  at  that  distance  for 
some  moments,  the  eye  will  then  rotate  inward.  In  such  cases 
there  is  apt  to  be  a  recurrence  of  the  strabismus. 

Advancement. — In  cases  of  convergent  squint,  in  which  it  is 
desirable  to  combine  advancement  of  the  external  rectus  with 
tenotomy  of  the  internal  rectus,  the  latter  is  done  first,  as  above 
described,  at  the  same  sitting. 

An  opening  is  then  made  in  the  conjunctiva  immediately  over 
the  insertion  of  the  external  rectus,  and  as  long  as  the  breadth 
of  the  tendon.  The  band  of  conjunctiva  between  the  opening 
and  the  cornea  is  separated  up,  with  the  scissors,  from  the 
sclerotic,  for  to  it  the  tendon  has  to  be  fastened  later  on.  A 
strabismus  hook  is  now^  passed  under  the  tendon  and  brought 
well  up  to  its  insertion,  care  being  taken  that  the  whole  width 
of  the  tendon  is  held  on  the  hook.  A  needle  carrying  a  fine 
silk  suture  is  introduced  from  its  upper  margin  between  the 
tendon  and  sclerotic,  and  passed  through  the  tendon  at  its  middle 
line.  In  the  same  way,  another  suture  is  passed  behind  the 
tendon  from  its  low^er  margin,  and  through  it,  close  to  the  first 
suture.  Each  of  these  sutures  is  knotted  firmly  on  the  tendon, 
a  long  end  being  left  to  each  (Fig.  161).  The  tendon  is  sepa- 
rated off  with  the  scissors  from  the  sclerotic,  close  to  its  insertion. 
The  sutures  are  passed  through  the  conjunctival  flap  in  the 
direction  of  the  muscle,  and  are  respectively  tied  with  their  own 
ends.  A  greater  or  less  effect  is  produced,  according  as  the 
sutures  are  placed  further  or  nearer  to  the  insertion  of  the 
tendon,  and  according  as  they  are  drawn  more  or  less  tightly. 
I  have  found  this  method  perfectly  satisfactory. 

Immediately  after  the  combined  operation  is  finished,  there 


THE   ORBITAL   MUSCLES. 


475 


should  be  no  divergence,  nor  should  there  be  marked  loss  of 
motion  of  the  eyeball  inward.  In  either  case  the  effect  is  too 
great,  and  must  at  once  be  diminished  by  an  adjustment  of 
the  advancing  sutures,  or  a  bringing  forward  of  the  internal 
rectus. 

In  my  opinion,  even  if  it  lie  in  the  plan  of  the  treatment  to 
supplement  the  tenotomy,  or  combined  operation^  on  the  squint- 
ing eye  by  a  tenotomy,  or  combined  operation,  on  the  fixing 
eye,  both  eyes  should  not  be  operated  on  at  one  and  the  same 

Fig.  161. 


sitting.  An  interval  of  a  fortnight  or  more  should  elapse,  in 
order  that  the  true  effect  of  the  first  proceeding  may  be  accu- 
rately gauged,  and  then  the  surgeon  will  be  in  a  position  to  know 
how  to  regulate  his  operative  measures  for  the  other  eye. 

After  a  strabismus  operation,  a  light  bandage  is  applied,  and 
is  changed  morning  and  evening  for  forty-eight  hours,  when, 
if  no  suture  has  been  used,  it  may  be  discarded.  If  sutures 
have  been  employed,  the  bandage  is  retained  until  they  come 
away. 

Dangers  of  the  Strabismus  Operation. — I  have  never  seen  any 


476  DISEASES   OF   THE    EYE. 

inflammatory  reaction  after  a  strabismus  operation,  not  even 
after  an  advancement,  nor  have  I  ever  seen  any  serious  accident 
during  the  operation.  Puncture  of  the  sclerotic  with  the  scis- 
sors, while  the  tendon  was  being  divided,  has  occurred  in  the 
hands  of  some  operators  ;  but,  I  confess,  I  cannot  understand 
how  such  an  accident  could  happen,  unless  the  operator  had 
his  own  eyes  shut.  It  is  also  stated  that  eyes  have  been  lost 
after  squint  operations  through  orbital  cellulitis,  which,  I  fancy, 
must  have  been  brought  on  by  the  introduction  of  septic  matter 
upon  the  instruments. 

Occasionally,  a  small  arterial  branch  may  be  divided  during 
the  operation,  and  this,  bleeding  into  the  capsule  of  Tenon,  may 
cause  rather  alarming  exophthalmos.  The  protrusion  goes  back 
in  a  few  days  with  use  of  a  pressure  bandage.  I  have  only  seen 
the  occurrence  twice. 

Sinking  of  the  caruncle,  some  months  after  the  tenotomy, 
when  it  does  rarely  occur,  can  be  remedied  in  the  following 
way:  The  conjunctiva  is  divided  vertically  about  6  mm.  from 
the  caruncle.  The  inner  lip  of  the  wound  is  raised,  a  scissors 
curved  on  the  flat  passed  in,  and  the  subconjunctival  tissue  as  far 
as  under  the  sunken  caruncle  separated.  The  subconjunctival 
tissue  under  the  outer  lip  of  the  wound,  and  as  far  as  the  corneal 
margin,  is  loosened  in  the  same  w^ay,  and  the  two  flaps  are 
brought  together  with  a  suture,  which  includes  a  sufliciency  of 
conjunctiva  to  draw  the  caruncle  well  forward. 

Treatment  Subsequent  to  Operation. — It  is  generally  necessary 
for  the  patient  to  wear  the  correcting  spectacles  for  his  hyper- 
metropia,  either  constantly,  or  for  near  vision  only,  according 
as  the  result  of  the  operative  measures  makes  it  more  or  less 
desirable  to  suspend  the  accommodation.  After  some  months, 
it  is  usually  possible  to  leave  off"  the  spectacles,  except  for  near 
vision. 

A  cure  of  the  strabismus,  in  the  sense  of  removal  of  the 
deformity,  can  be  attained  by  operation  in  every  case  ;  and,  by 
itself,  affords  ample  reason  for  undertaking  the  operation.  But 
a  cure,  in  the   true  sense  of  the  term,   involves  restoration   of 


THE    ORBITAL    MUSCLES.  477 

binocular  vision*,  and  this  is  very  rarely  obtained  by  operative 
measures  alone. 

Orthoptic  exercises  with  the  stereoscope  (p.  467)  are  of  great 
value  in  completing  a  cure,  which  has  been  almost  effected  by 
operation.  The  deviation,  which  has  been  reduced  to  a  minimum 
by  the  operation,  may  sometimes  be  quite  eliminated,  and,  still 
more  important,  binocular  vision  may  sometimes  be  developed. 
Where  the  attending  circumstances  of  the  case,  both  clinical 
(acuteness  of  vision,  diplopia)  and  personal  (patience  and  intel- 
ligence of  the  patient),  admit  of  it,  an  effort  should  always  be 
made  to  effect  such  a  cure. 

Insufficiency  of  Convergence,  or  Insufficiency  of  the  Internal 
Recti  Muscles,  and  Divergent  Concomitant  Strabismus. — In  the 
normal  condition,  the  orbital  muscles  are  in  a  state  of  equili- 
brium, no  one  muscle,  or  pair  of  muscles,  having  more  power 
over  the  eyeballs  than  its  fellow. 

Insufficiency  of  the  Internal  Recti  Muscles,  or  Insufficiency  of 
Convergence,  implies  a  disturbance  of  this  equilibrium.  The 
internal  recti  in  these  cases  are  so  much  weaker  than  the  exter- 
nal recti,  that  the  former  are  obliged  to  make  a  constant  effort  to 
prevent  the  eyes,  or  one  of  them,  from  becoming  divergent,  and 
it  is  only  the  demand  for  binocular  vision  which  stimulates  the 
muscles  to  this  effort. 

Muscular  Asthenopia  is  the  symptom  caused  by  this  insuffi- 
ciency. The  patients  complain  that,  after  reading,  writing,  sew- 
ing, or  employment  at  other  near  work  for  a  time,  they  begin  to 
find  the  objects  spreading,  becoming  indistinct,  and  perhaps 
doubled.  Pain  in  and  about  the  eyes  comes  on.  These  symp- 
toms gradually  increase,  until  the  work  has  to  be  discontinued. 

A  great  deal  has  been  written  within  recent  years  upon  the 
relationship    of  some   nervous    diseases,  especially  epilepsy,   to 


■*  The  importance  of  binocular  vision  consists  in  the  fact  that  it  is 
chiefly  by  its  aid  we  estimate  distances  finely,  and  observe  the  shape  of 
objects.  Even  plane  surfaces  are  seen  much  more  accurately  with  bin- 
ocular than  with  monocular  vision. 


478  DISEASES   OF   THE    EYE. 

waut  of  power  in  one  or  more  of  the  orbital  muscles.  It  has 
been  thought  that  "eye  strain,"  from  want  of  coordination  in 
these  muscles,  sometimes  aggravated,  if  it  did  not  actually  cause, 
epilepsy ;  but  the  outcome  of  the  whole  discussion  seems  to  be 
that  there  is  no  such  connection. 

The  diagnosis  of  insufficiency  of  convergence  can  be  made 
by  the  following  methods.  The  patient  is  directed  to  look  at  the 
tip  of  the  surgeon's  finger  held  up  in  the  middle  line.  The 
finger  is  brought  slowly  closer  to  the  eyes  until  a  certain  point 
is  reached  where  the  internal  rectus  of  one  eye  ceases  to  act,  the 
other  eye  still  remaining  in  fixation.  The  first  eye, 
'  upon  the  finger  being  advanced  a  little  more,  usually 
becomes  divergent. 

Or,  if  the  tip  of  the  finger  be  held  some  20  cm.  from 
the  patient's  eyes,  and  if,  with  his  other  hand,  the  sur- 
geon cover  one  of  the  eyes,  say  the  right,  while  the  left 
is  caused  to  fix  the  finger-tip,  it  will  be  found  that  the 
eye  under  the  hand  is  diverging,  and,  when  the  hand  is 
removed  from  it,  it  makes  an  inward  motion,  in  order 
again  to  fix  the  finger-tip.  The  explanation  of  this  is^ 
that,  when  one  eye  is  covered,  there  is  nothing  to  be 
gained  in  the  way  of  single  vision  by  an  excessive 
exertion  of  the  weak  internal  recti ;  and,  consequently, 
the  eye  which  is  excluded  from  the  act  of  vision  is  abandoned 
to  the  control  of  the  over-strong  external  rectus,  and  only  re- 
turns to  its  normal  position,  when,  being  restored  to  participa- 
tion in  the  act  of  vision,  diplopia  would  otherwise  be  present. 
The  following  is  von  Graefe's  Test  for  Insufficiency  of  the 
Internal  Recti :  A  dot  with  a  line  drawn  vertically  through  it 
(Fig.  162)  on  a  sheet  of  white  paper  is  given  to  the  patient  to 
look  at,  at  his  usual  reading  distance.  Before  one  eye,  say  the 
right,  a  prism  of  about  10°  with  its  base  downward  is  held 
vertically.  This,  in  the  normal  condition,  would  produce  a 
double  image  of  the  dot,  so  that  the  figure  would  seem  to  be  a 
line  with  two  dots,  the  upper  dot  being  the  image  belonging  to 
the  right  eye.     In  insufficiency  of  the  interni,  the  image  of  the 


THE   ORBITAL   MUSCLES. 


479 


right  eye  would  not  only  be  higher  than  that  of  the  left,  but  it 
would  also  stand  to  the  left  (crossed  double  images)  more  or 
less,  so  that  here  the  picture  is  that  of  two  lines,  each  with  a 
dot,  the  upper  line  and  dot  standing  to  the  left-hand  side  (Fig. 
163).  This  crossed  diplopia  indicates  divergence.  The  expla- 
nation of  the  experiment  is  as  follows :  When  a  prism  is  held 
before  the  right  eye,  the  possibility  of  binocular  vision  is 
removed,  and,  insufficiency  existing,  the  weak  internal  rectus  of 
the  right  eye  has  no  object  in  greatly  exerting  itself,  and  con- 
sequently abandons  the  eye  to  the  traction  of  the  external  rectus. 
Hence  the  divergence,  and  the  projection  of  the  image  of  this 
eye  to  the  opposite  side. 

The  degree  of  insufficiency  existing  may  be  determined  by 
this  same  experiment.  If  a  weak  prism  be  held  with  its  base 
inward  before  the  left  eye,  in  the  above  case,  the  images  of  the 
lines  will  appear  to  be  brought  closer.  By  gradually  increasing 
the  power  of  the  prism,  one  will  be  found  which 
brings  the  lines  together,  so  that  the  picture  will 
now  be  that  of  two  dots  over  each  other  on  one  line. 
This  prism  is  the  measure  of  the  insufficiency. 

Landolt  estimates  the  amount  of  insufficiency  of 
convergence  by  means  of  the  metre  angle  and 
amplitude  of  convergence.  For  an  account  of  the 
method  I  must  refer  the  reader  to  his  valuable 
work.* 

Maddox's  Rod  Test  is  an  admirable  method  for 
ascertaining  the  condition  of  the  muscular  equili- 
brium of  the  eyeballs,  and  for  estimating  any  exist- 
ing derangement  of  it. 

The  apparent  lengthening  of  a  flame  into  a  line  of 
light,  when  looked  at  through  a  strong  cylinder,  is 
utilized  to  make  the  two  images  so  dissimilar  that  no 
desire  to  unite  them  remains.  The  chief  advantage  of 
this  principle  is  that  slight  malpositions  do  not,  as  with 


Fig.  163. 


The  Refraction  and  Accommodation  of  the  Eye,"  1886,  p.  501, 


480 


DISEASES    OF    THE    EYE. 


Fig.  164. 


prisms,  vitiate  the  result  materially.  A  glass  rod  mounted  in  a 
circular  metal  disc,  as  in  Fig,  164,  may  be  used ;  or  a  piano- 
cylinder  with  a  radius  of  about  20  mm. ;  or  a  piece  of  corrugated 
glass ;  or  a  flat  series  of  thin  glass  rods  side  by  side.  The  best 
flame  is  that  of  a  gas-jet  turned  low,  at  a  distance  of  5  mm.  or 
6  mm.,  and  the  appearance  is  improved  by  a  piece  of  blue  glass 
before  the  other  eye,  to  equalize  the  illumination  of  the  two 
images.  The  line  of  light  is  at  right  angles  to  the  axis  of  the 
cylinder.  If  it  pass  through  the  flame  the  balance  is  perfect ; 
if  not,  the  defect  is  measured  by  the  deviating  angle  of  the 
prism  which  is  found  to  bring  them  together,  or  preferably,  by  a 
lithographed  scale,  placed  with  its  zero  just  behind  the  flame,  so 
that  the  figure  crossed  by  the  line  of  light  gives  the  deviation  in 
degrees.     For  vertical  diplopia  the  scale  should  be  vertical,  and 

for  horizontal  diplopia  horizontal. 
In  either  case  the  axis  of  the 
cylinder  should  be  parallel  to  the 
scale.  When  the  cylinder  is  verti- 
cal, it  should  be  shaded  from  the 
light  of  the  window.  By  placing 
the  patient's  head  in  different  posi- 
tions, the  diplopia  can  be  measured 
in  all  parts  of  the  motor  field. 
Vertical  and  horizontal  scales 
should,  for  this  purpose,  be  fixed  on 
the  wall,  with  their  zeroes  coincid- 
ing at  the  position  of  the  flame.  For  near-vision  tests,  a  flame 
is  too  large.  A  scale  should  be  used  on  a  black  background, 
with  a  small  silvered  hemisphere  or  bead  fixed  to  its  zero,  to  be 
a  source  of  reflected  light  from  the  window  or  from  a  flame. 

This  test  is  also  very  serviceable  in  overcoming  the  suppres- 
sion of  the  false  image  in  old  squints,  and  for  discovering  the 
latent  paresis  of  an  ocular  muscle. 

Insufficiency  of  the  internal  recti  is  a  common  attendant  upon 
myopia,  and  is  probably  congenital,  like  the  myopia.  It  is  also 
found  with  emmetropia,  and  even  with  hypermetropia. 


THE    ORBITAL    MUSCLES.  481 

Concomitaut  divergent  strabismus  is  a  further  development 
of  the  same  condition. 

Treatment. — In  moderate  degrees  of  myopia,  the  use  of  such 
concave  glasses  as  will  permit  the  patient  to  read  at  35  cm. 
distance  may  relieve  the  asthenopic  symptoms. 

Decentration  of  these  glasses  may  give  further  aid.  If  the 
glasses  be  so  set  in  the  spectacle  frame  that  their  centres  are  on 
the  outer  side  of  the  visual  lines,  the  inner  half  of  the  glasses  act 
as  prisms  with  their  bases  inward  (Chap.  I,  p.  2),  and  by  them 
the  rays  are  broken  inward,  i.  e.,  toward  the  macula  lutea  in  each 
eye,  so  that  a  slight  divergence  may  take  place  without  diplopia, 
etc.  In  this  way  the  internal  recti  are  relieved.  Should  the 
case  be  one  demanding  the  use  of  convex  glasses  (hypermetropia, 
presbyopia),  the  decentration  must  be  inward. 

A  more  perfect  and  accurate  method  is  that  of  prescribing 
prisms,  bases  inward,  to  be  worn  for  reading  and  other  near 
work.  These  may  be  combined  with  concave  or  convex  glasses, 
where  such  are  indicated.  The  prism  which  is  the  measure  of 
the  insufficiency  (see  above)  is  divided  between  the  two  eyes. 
If  it  be  4°,  a  prism  of  2°  is  placed,  base  inward,  before  each  eye 
for  near  work.  Very  high  prisms  cannot  be  ordered,  owing  to 
the  color  effects  they  produce;  and,  in  cases  where  they  would 
be  required,  the  insufficiency  can  be  only  partially  corrected. 

Operative  Treatment. — This  consists  in  weakening  the  too 
strong  external  rectus  by  tenotomy.  The  danger  of  the  method 
is,  that  convergent  strabismus  with  homonymous  diplopia  for 
distant  objects  might  result,  unless  the  case  be  suitable  for 
operation.  Only  those  cases  are  suitable  in  which  absolute 
divergent  strabismus  is  present;  or  those  in  which,  with  a  prism 
of  not  less  than  10°,  base  inward,  before  one  eye,  the  flame  of  a 
candle  at  3  mm.  distance  is  seen  single,  or  if  it  be,  perhaps, 
doubled  for  a  moment,  then  becoming  again  single.  When, 
with  such  a  prism,  single  vision  is  present,  the  external  rectus 
by  an  effort  must  have  overcome  the  effect  of  the  prism,  and  it 
is  admissible  to  deprive  the  muscle  of  the  power  represented  by 
that  effort  or  prism.  If  diplopia  be  produced  by  a  prism  of  10^, 
41 


482  DISEASES    OF    THE    EYE. 

the  tenotomy  is  contraindicated,  for  the  effect  of  the  latter  could 
not  be  modified  to  the  slight  power  of  abduction  indicated  by  a 
weaker  prism.  A  source  of  error  in  the  ascertaining  of  this 
abduction  prism  which  must  be  guarded  against  is,  that  the 
patient  may  suppress  the  image  of  one  eye,  and  that  his  single 
vision  may  be  merely  due  to  the  fact  that  he  is  seeing  with  the 
other  alone.  The  higher  the  abduction  prism,  the  more  exten- 
sive may  be  the  division  of  the  subconjunctival  tissue,  etc.,  while 
with  weak  abduction  the  effect  must  be  diminished  by  a  con- 
junctival suture. 

Immediately  after  the  operation  there  should  be  a  certain 
amount  of  convergence,  as  shown  by  homonymous  diplopia  in 
the  middle  line  for  the  flame  of  a  candle  at  three  mm.  distance. 
This  convergence,  or  diplopia,  should  not  be  greater  than  can  be 
corrected  by  a  prism  of  10°.  Moreover,  if  the  candle  be  moved 
from  the  middle  line  15°  to  the  opposite  side  from  the  operated 
muscle  (to  the  right  if  the  left  external  rectus  has  been  tenoto- 
mized),  there  should  be  no  convergence  (no  diplopia),  and  a 
vertical  prism  before  one  eye  should  only  cause  double  images 
placed  directly  over  each  other.  If,  by  these  experiments,  it  be 
shown  that  the  operation  has  produced  an  excessive  effect,  the 
latter  must  be  diminished  by  a  suture  drawing  the  lips  of  the 
conjunctival  wound  together,  and  including  more  or  less  con- 
junctiva, according  to  the  excess  to  be  corrected.  Or,  if  a  suture 
have  already  been  applied,  and  the  result  be  still  in  excess,  it 
must  be  withdrawn,  and  a  still  more  restricting  suture  inserted. 
In  all  these  cases,  convergence  must  necessarily  be  present  when 
the  candle  is  carried  over  to  the  side  of  the  operated  muscle  ;  but 
this  disappears — except,  perhaps,  at  the  very  most  extreme 
position  on  that  side— as  also  the  convergence  in  the  middle 
line,  by  reason  of  cicatricial  contraction  at  the  new  insertion  of 
the  tendon ;  always  provided,  that  the  indications  for  the  opera- 
tion and  its  performance,  as  above  set  forth,  have  been  accu- 
rately attended  to. 


the  orbital  muscles.  483 

Nystagmus. 

This  term  indicates  an  involuntary  oscillation  of  the  eyeballs 
from  side  to  side  (the  most  common  form),  in  the  vertical  direc- 
tion, or  rotary  (caused  by  the  oblique  muscles). 

It  is  most  commonly  found  with  congenitally  defective  vision 
— microphthalmos,  coloboma  of  the  choroid,  in  albinos,  etc. — 
but  it  may  be  acquired,  and  is  often  seen  in  those  employed  in 
coal  mines.  It  occurs  in  about  one-half  the  cases  of  disseminated 
sclerosis,  and,  as  it  is  rarely  met  with  in  tabes  or  other  chronic 
nervous  disorders,  it  is  here  a  symptom  of  diagnostic  value. 

In  the  congenital  cases  it  is  probable  that  the  absence  of  the 
stimulus  which  accurate  retinal  impressions  afford  interferes 
with  the  functional  development  of  the  coordinating  centres  for 
the  orbital  muscles.  In  coal  mines,  the  very  defective  light, 
and  the  blackness  of  the  surroundings,  deprive  the  miners  of  any 
defined  retinal  impression,  and  hence  their  coordinating  centres 
are  apt  to  become  deranged.  But,  as  it  is  chiefly  those  who 
work  in  one  constrained  position  on  their  sides,  with  eyes  directed 
obliquely  upward,  who  become  affected,  it  seems  likely,"^  that  this 
unnatural  and  long-continued  direction  of  the  eyeballs  is  an  im- 
portant factor  in  the  production  of  the  affection  ;  indeed,  it  is  prob- 
ably to  a  great  extent  a  professional  cramp,  like  writers'  cramp. 

Those  patients  in  whom  nystagmus  is  due  to  a  congenital 
defect  of  vision,  do  not  complain  of  oscillation  of  the  objects  they 
look  at ;  but  individuals  who  become  affected  with  it  in  later 
life  are  much  troubled  with  that  symptom,  especially  at  the  onset. 

Treatment. — In  congenital  cases  which  admit  of  improvement 
of  vision,  a  cure,  partial  or  complete,  is  sometimes  brought 
about,  when  the  vision  improves.  If  strabismus  be  present,  it 
should  be  cured,  after  which  a  diminution  in  the  oscillations 
may  result.  In  miners'  nystagmus,  the  all  important  measure 
is  a  permanent  relinquishment  of  mine  work;  and  this  is 
frequently  followed  by  satisfactory  results. 

"^Vide  S.  Snell,  Brit  Med.  Jovrn.,  July  11th,  1891. 


CHAPTER   XIX. 
DISEASES    OF    THE    ORBIT. 

Orbital  Cellulitis,  or  Inflammation  of  the  Connective  Tissue 
of  the  Orbit. —  The  Symptoms  of  this  affection  are:  Erysipela- 
tous swelling  of  the  lids,  especially  of  the  upper  lid  ;  serous 
chemosis  ;  pain  in  the  orbit,  increased  on  pressure  of  the  eyeball 
backward  ;  violent  facial  neuralgia ;  exophthalmos,  with  impair- 
ment of  the  motions  of  the  eye  in  every  direction  ;  and  high 
fever. 

Vision  is  not  generally  affected,  but  sometimes  it  is  so  from 
optic  neuritis,  and  then,  too,  mydriasis  is  seen.  The  cornea  is 
often  completely  or  partially  anaesthetic. 

The  surgeon,  by  pressing  the  tip  of  his  fourth  finger  between 
the  eyeball  and  the  margin  of  the  orbit,  may  feel  a  more  or  less 
resistant  tumor.  This  gradually  increases  in  some  one  direction, 
the  integument  in  that  position  becomes  redder,  fluctuation  be- 
comes pronounced,  and  the  abscess  finally  opens  through  the 
skin,  or  into  the  conjunctival  sac,  the  pointing  being  usually  at 
the  upper  and  inner  angle  of  the  orbit.  Restoration  to  the  nor- 
mal state,  as  a  rule,  comes  about;  but,  in  some  cases,  complete 
atrophy  of  the  optic  nerve  supervenes. 

Causes. — 1.  Idiopathic  (e.  g.,  cold)  ;  2.  Traumatic  (perforating 
injuries,  foreign  bodies) ;  3.  Extension  of  inflammation  from 
surrounding  parts  (erysipelas,  diseased  tooth,  ethmoidal  cells)  ; 
4.  Metastasis  (pyaemia,  metria)  ;  5.  Sequelae  of  fevers  (scarla- 
tina, typhoid,  purulent  meningitis). 

Treatment. — Locally,  poultices  or  warm  fomentations  ;  and, 
when  pus  has  formed,  its  earliest  possible  evacuation, — by  pre- 
ference from  the  conjunctival  sac.  The  general  constitutional 
treatment  suitable  to  each  case  ireed  not  be  discussed  here. 

484 


THE   ORBIT.  485 

Periostitis  of  the  Orbit. — Acute  periostitis  has  many  symp- 
toms in  common  with  phlegmonous  inflammation  of  the  orbital 
connective  tissue  which  generally  accompanies  it ;  but  may 
usually  be  distinguished  from  the  latter  inflammation  occurring 
independently,  by  the  fact,  as  first  pointed  out  by  the  late  Mr. 
John  Hamilton,  of  Dublin,^  that,  in  it,  pressure  on  the  orbital 
margin  is  painful.  The  absence  of  this  tenderness,  however,  is 
not  always  conclusive  of  the  absence  of  periostitis,  especially 
when  the  latter  is  restricted  to  the  deep  parts  of  the  orbit.  In 
periostitis  the  eyeballs  are  not  usually  so  swollen  as  in  inflam- 
mation of  the  orbital  tissues.  Suppuration  may  take  place, 
necrosis  in  consequence  of  detachment  of  the  periosteum  may 
come  on,  and  communications  with  the  neighboring  cavities  be 
formed. 

In  secondary  syphilis,  or  in  later  stages  of  the  disease,  a 
syphilitic  gumma  of  the  orbital  wall  may  form.  This  is  ac- 
companied by  violent  frontal  neuralgia  or  headache,  increasing 
at  night.  Proptosisf  {~po,  forward;  -rwfTt?,  falling),  occurs 
with  marked  loss  of  motion  of  the  eyeball  in  one  or  more  direc- 
tions. This  loss  of  motion  is  a  very  characteristic  symptom,  and 
serves  to  assist  in  the  diagnosis  between  this  affection  and  other 
orbital  tumors.  It  is  probably  due  to  an  extension  of  the 
inflammation  to  the  connective  tissue  of  the  orbit,  and  to  the 
muscles  themselves. 

Again  periostitis  of  a  chronic  form,  and  without  tendency  to 
suppuration,  occurs  most  commonly  in  persons  with  a  constitu- 
tional rheumatic  tendency.  It  is  accompanied  by  pain  in  and 
about  the  orbit,  and  there  is  increased  tenderness  on  pressure  of 
the  eyeball  backward.  Exophthalmos,  and  all  other  outward 
signs,  are  usually  wanting. 

The  Prognosis  depends  much  on  the  seat  of  the  inflammation. 
If  this  be  in  the  deep  parts  of  the  orbit,  thickening  of  the  peri- 
osteum may  cause  permanent  protrusion  of  the  eyeball ;  exten- 

*  Dublin  Journal  of  Medical  Sciences^  1836. 
t  Protrusion  of  the  eyeball. 


486  DISEASES    OF    THE    EYE. 

sion  of  the  inflammation  of  the  optic  nerve  may  result  in  optic 
atrophy  ;  the  orbital  muscles,  or  the  nerves  which  supply  them, 
may  be  implicated,  with  consequent  paralysis;  or,  finally,  the 
periostitis  may  strike  into  the  meninges  of  the  brain.  When 
the  inflammation  is  near  the  margin  of  the  orbit,  early  evacua- 
tion of  pus,  if  it  has  formed,  reduces  the  process  within  safe 
bounds ;  and  this  position  is  one  of  less  danger  in  respect  of  its 
surroundings. 

Causes. — Periostitis  of  the  orbit  may  be  caused  by  blows  or 
other  traumata,  by  extension  from  neighboring  cavities,  by 
syphilis,  or  rheumatism. 

Treatment. — Warm  fomentations.  Exit  given  to  pus,  if  pos- 
sible.    Constitutional  measures. 

Caries  of  the  Orbit  is  very  frequently  the  result  of  periostitis, 
but  often  commences  in  the  bone,  and,  in  either  case,  is  usually 
due  to  tubercular  disease  of  the  bone.  It  is  also  seen  in  very 
late  syphilis.  A  trauma  is  sometimes  the  immediate  cause  of  its 
onset. 

It  may  attack  any  part  of  the  orbital  walls,  its  favorite  seats 
being  the  margin  above  and  to  the  outside,  or  below  and  to  the 
outside.  When  it  is  seated  deeply  in  the  orbit,  it  often  causes 
exophthalmos  and  pain.  At  the  margin  of  the  orbit  it  produces 
cedema  and  swelling  of  the  eyelids  with  conjunctivitis,  suppura- 
tion comes  on,  and  the  abscess  finally  opens  through  the  integu- 
ment or  conjunctiva.  A  fistula  is  apt  to  remain  for  a  length  of 
time,  and,  the  skin  being  drawn  into  this,  ectropion  of  the  lid  is 
produced.  If  a  portion  of  dead  bone  come  away,  the  resulting 
cicatrix  is  liable  to  maintain  the  ectropion  (p.  169). 

Treatment. — The  evacuation  of  purulent  collections  at  the 
earliest  possible  moment — if  deep  in  the  orbit,  by  the  careful 
introduction  of  a  long  bistoury — the  insertion  of  a  drainage- 
tube,  and  the  regular  washing  out  of  the  cavity  with  antiseptic 
solutions,  until  no  more  rough  or  bare  bone  can  be  felt  with  the 
probe. 

Injuries  of  the  Orbit. — Wounds  of  the  soft  parts  in  the  supra- 
orbital region,  involving  the  supra-orbital  nerve,  are  believed 


THE    ORBIT.  487 

by  some  to  be  capable  of  producing  a  reflex  amaurosis  (p.  418), 
and  many  such  cases  have  been  recorded  under  the  name  of 
supra-orbital  amaurosis.  By  the  light  of  modern  physiology 
and  ophthalmology  it  is  not  probable,  I  might  say  not  possible, 
that  any  such  reflex  could  take  place,  and  it  seems  likely  that 
the  blindness  in  those  recorded  cases  was  brought  about  in  some 
other  way,  e.g.,  orbital  periostitis,  concomitant  injury  to  the 
eyeball  itself,  facial  erysipelas,  intracranial  lesions,  and  so  on. 

Perforating  injuries  of  the  orbit  through  the  eyelids  by  prods 
of  walking-canes,  etc.,  and  the  lodgment  of  foreign  bodies  in  the 
orbit,  are  serious  accidents.  They  are  liable  to  be  followed  by 
phlegmonous  inflammation,  or,  if  a  pointed  weapon  (stick, 
sword-cane,  etc.)  has  been  pushed  into  the  orbit  with  some  force, 
it  may  pass  through  the  bony  wall  and  perforate  the  brain,  with 
fatal  result. 

It  is  remarkable  what  large  foreign  bodies  may  be  concealed 
in  the  orbit.  I  saw  a  case  in  which  a  bit  of  wood,  f-inch  long 
by  2-inch  wide,  lay  unsuspected  in  the  orbit  for  many  weeks, 
without  causing  any  marked  displacement  of  the  eyeball. 

Treatment. — Foreign  bodies  should  be  removed  by  dilatation  of 
their  wounds  of  entrance,  or  by  the  formation  of  a  new  passage 
through  the  conjunctival  fornix — and  great  care  should  be 
taken  to  prevent  the  onset  of  inflammation  or  to  keep  it  within 
safe  bounds. 

Tumors  of  the  Orbit  necessarily  give  rise  to  proptosis,  and  the 
motions  of  the  eyeball  are  generally  impaired.  Vision  often 
remains  good  until  a  very  late  period,  unless,  as  rarely  occurs, 
the  optic  nerve  should  early  become  involved  in  the  growth  ; 
but,  ultimately,  optic  neuritis,  or  optic  atrophy  induces  blind- 
ness. The  upper  lid,  becoming  wonderfully  enlarged,  protects 
the  cornea  from  exposure  and  consequent  ulceration,  until,  at 
last,  the  excessive  protrusion  of  the  eyeball  no  longer  admits  of 
this,  and  the  cornea  sloughs. 

When  the  tumor  has  attained  a  certain  size,  it  may  be  felt  by 
the  tip  of  the  finger  passed  into  the  orbit,  and  some  idea  of  its 
consistency  and  mobility  can  be  formed. 


488  DISEASES   OF   THE    EYE. 

Ill  every  case,  the  history,  the  rapidity  of  growth,  and  the 
general  condition  of  the  patient  are  important  items  for  con- 
sideration. 

Cysts. — Dermoid  cysts  are  amongst  those  most  frequently 
found.  They  grow  slowly,  and  finally  reach  very  considerable 
size,  and  then  bulge  out  between  the  eyeball  and  margin  of  the 
orbit.  Pressure  upon  this  protruding  part  causes  it  to  diminish, 
while  the  exophthalmos  is  at  the  same  time  increased,  and  dis- 
tinct fluctuation  in  the  protruding  part  can  be  felt.  The  growth 
of  the  cyst  is  unaccompanied  by  pain  or  other  inconvenience. 
The  contents  are  generally  either  serous  or  honey-like,  and, 
occasionally,  hairs  and  other  epidermic  formations  have  been 
found  in  them. 

A  mucocele  originating  in  the  frontal  or  in  the  ethmoid  sinus 
may  absorb  the  orbital  wall,  protrude  into  the  orbit,  and  give 
rise  to  all  the  signs  and  symptoms  of  a  true  orbital  tumor. 

Treatment. — The  cyst  should  be  freely  opened  at  the  most 
prominent  point,  evacuated  by  gentle  pressure  backward  of  the 
eyeball,  and  the  sac  syringed  out  two  or  three  times  daily  with 
an  antiseptic  solution,  until  all  discharge  has  ceased.  The 
opening  will  then  close,  while  the  eyeball  will  already  have 
returned  to  its  place.  If  the  contents  of  the  cyst  are  solid,  or 
nearly  so,  it  becomes  necessary  to  extirpate  it  in  toto.  To  do 
this,  as  in  other  tumors  also,  a  horizontal  incision  must  be  made 
along  the  orbital  margin  through  the  eyelid,  in  order  that  the  cavity 
of  the  orbit  may  be  reached ;  or,  two  perpendicular  incisions  at 
either  canthus  through  the  upper  lid  may  be  made,  and  the 
latter  turned  upward.  With  hooks  or  forceps,  and  scalpel  or 
scissors,  the  cyst  wall  must  then  be  carefully  separated  from  all 
adhesions. 

Exostoses  occur  as  the  result  of  inflammation  of  the  bone  and 
of  periostitis,  and  are  usually  of  the  kind  known  as  ivory  exos- 
toses. They  spring  most  commonly  from  the  ethmoid,  or  from 
the  frontal  bone.  Their  surface  is  tuberous.  Their  growth  is 
extremely  slow,  in  many  instances  commencing  in  infancy  and 
lasting  into  advanced  life. 


THE    ORBIT.  489 

Operative  iuterference  in  cases  of  exostosis  of  the  orbit  is 
only  justifiable  when  the  tumor  does  not  grow  from  the  roof  of 
the  orbit,  and  where  there  is  reason  to  think  it  is  attached  to 
the  orbital  wall  by  a  narrow  base  or  pedicle.  Several  instances 
are  on  record  in  which  the  growth  has  become  spontaneously 
separated  by  necrosis  of  its  pedicle.  Beyond  destruction  of  the 
eyeball,  there  is  no  danger  associated  with  these  tumors,  even  if 
their  growth  take  an  intracranial  direction ;  but  they  cause 
serious  disfigurement  and  much  pain. 

Carcinoma  and  Sarcoma. — The  first  of  these  tumors  takes  its 
origin  in  some  neighboring  cavity  and  grows  into  the  orbit,  or 
it  may  start  from  the  orbital  walls,  or  from  the  retro  bulbar 
connective  tissue.  Sarcoma  may  originate  in  many  diflferent 
positions,  most  frequently,  perhaps,  in  the  periosteum,  and  in 
the  connective  tissue  about  the  lachrymal  gland.  These  malig- 
nant tumors,  after  destruction  of  the  eyeball  by  pressure,  or  by 
phthisis  following  ulceration  of  the  cornea,  attack  the  bony 
walls  of  the  orbit  and  its  surroundings.  Many  forms  of  sar- 
coma, however,  are  non-malignant. 

The  early  extirpation  of  the  tumor  affords,  in  general,  the 
only  prospect  of  saving  the  patient's  life. 

Pulsating  Exophthalmos. — This  title  includes  a  great  variety 
of  vascular  tumors,  the  majority  of  them  having  their  origin 
within  the  cranium,  while  the  remainder  are  truly  orbital. 
Symptoms  common  to  all  these  are :  Proptosis ;  the  presence 
of  peculiar  bruits  which  can  be  heard  over  the  orbit,  and  usually 
also  over  a  more  or  less  extensive  portion  of  the  skull ;  and 
pulsation,  apparent  in  the  eyeball,  or  at  some  point  of  the 
orbital  aperture.  The  last  symptom  may  occasionally  be  absent 
during  the  whole,  or  part,  of  the  progress  of  the  case.  The 
intracranial  vascular  tumors  with  which  we  are  most  likely  to 
have  to  deal  are :  Aneurism  of  the  ophthalmic  artery  at  its 
point  of  origin  from  the  internal  carotid;  aneurism  of  the  latter 
vessel;  and,  most  commonly,  arterio-venous  aneurism  from  com- 
munication of  the  internal  carotid  with  the  cavernous  sinus — 
this  latter    of  traumatic   origin.     In    the   orbit   the   following 


490  DISEASES   OF    THE    EYE. 

occur:  True  aueurism  of  any  of  the  arterial  branches;  diffused 
or  circumscribed  traumatic  aneurism;  arterio-venous  aneurism, 
of  traumatic  origin;  aneurism  per  anastomosis;  and  teliangiectic 
tumors. 

Hemorrhage  is  liable  to  prove  fatal  in  these  cases. 

Treatment. — Ligature  of  the  common  carotid  affords  the  best 
prospect  of  cure.  Digital  compression  of  the  same  vessel  has 
produced  cure  in  some  cases. 

Diseases  of  Neighboring  Cavities  are  sometimes  liable  to 
encroach  upon  the  orbital  space  and  to  displace  the  eyeball. 
The  frontal  sinus  and  the  antrum  of  Highmore  are  the  cavities 
which  chiefly  come  under  notice  here,  but  disease  of  the  eth- 
moidal and  sphenoidal  sinus  does  so  more  rarely. 

The  condition  in  these  cases  is,  as  a  rule,  retention  of  normal 
secretion  from  obstruction  of  the  outlet  of  the  cavity,  or  else 
empyema.  The  most  common  initial  cause  is  catarrh  of  the 
nasal  mucous  membrane  extending  into  these  cavities,  or  a  blow 
which  fractures  the  bone  in  such  a  way  as  to  occlude  the  ways 
of  exit.  Polypi  sometimes  grow  in  these  cavities  and  distend 
them. 

When  a  collection  of  fluid  occurs  in  the  frontal  sinus,  or  in 
the  antrum,  it  is  usually  present  for  a  long  time  before  the 
orbital  cavity  is  invaded  by  bulging  of  its  corresponding  wall, 
and  this  is  accompanied,  or  preceded,  by  a  swelling  in  the  fore- 
head or  cheek,  respectively.  Finally,  the  orbital  wall  is  apt  to 
become  perforated.  Then,  in  the  case  of  a  frontal  empyema,  an 
elastic  swelling  appears  at  the  upper  and  inner  angle  of  the 
orbit,  near  the  pulley  for  the  tendon  of  the  superior  oblique ; 
while,  in  the  case  of  the  antrum,  the  tumefaction  appears  between 
the  eyeball  and  the  inferior  orbital  margin.  The  eyeball  in  each 
instance  is  more  or  less  displaced  in  the  opposite  direction  and 
forward. 

As  there  is  no  frontal  sinus  in  children  under  eleven  years  of 
age,  frontal  empyema  cannot  occur  in  young  children. 

Prior  to  perforation  of  the  orbital  wall  the  only  Treatment  that 
can  be  adopted  is  the  formation,  by  means  of  a  gouge,  of  an 


THE   ORBIT.  491 

opening  into  the  cavity,  either  through  the  orbit  or  nostril  in 
the  case  of  frontal  disease,  or  through  the  orbit  or  cheek  in  the 
case  of  disease  of  the  antrum.  After  perforation,  evacuation  of 
the  fluid  must  of  course  be  made  where  it  points  in  the  orbit. 
When  the  fluid  has  been  evacuated,  the  cavity  must  be  washed 
out  daily  with  sublimate  or  astringent  lotions,  to  bring  about  a 
healthy  state  of  the  lining  mucous  membrane  and  to  arrest  the 
discharge.  But  the  complete  cure  of  these  cases  is  often  an 
extremely  tedious  matter,  and  may  extend  over  many  months. 

Empyema  of  the  Ethmoidal  Cells  presents  itself  as  an  orbital 
abscess,  pointing  at  the  upper  and  inner  angle  of  the  orbit, 
causing  displacement  of  the  eyeball  forward,  outward,  and 
downward.  It  is  not  possible  to  diagnose  with  certainty  the 
place  of  origin  of  the  abscess,  unless  some  of  the  purulent  dis- 
charge come  through  the  nostril.  After  the  abscess  has  been 
opened  lotions  syringed  into  the  opening  may  flow  out  by  the 
nose. 

Empyema  of  the  Sphenoidal  Sinus  is  extremely  rare,  and  is 
in  most  instances  difficult  or  impossible  of  diagnosis ;  for,  if  it 
give  rise  to  exophthalmos,  there  is  nothing  to  distinguish  the 
latter  from  protrusion  of  the  eyeball  due  to  many  other  causes. 

Ethmoidal  and  Sphenoidal  Empyema  may  produce  blindness 
by  pressure  on  the  optic  nerve,  or  by  setting  up  orbital  cellulitis. 

Hernia  Cerebri,  either  in  the  form  of  meningocele  or  of  en- 
cephalocele,  may  invade  the  orbit.  Its  most  common  situation 
is  the  upper  and  inner  angle  of  the  orbit,  to  which  it  gains 
access  through  the  suture  between  the  frontal  and  ethmoid 
bones.  It  appears  as  a  fluctuating,  often  transparent,  pulsating 
congenital  tumor.  Pressure  causes  it  to  disappear,  but  gives 
rise,  at  the  same  time,  to  symptoms  of  cerebral  irritation,  or 
pressure. 

A  congenital  tumor  in  the  upper  inner  angle  of  the  orbit 
must  always  be  regarded  with  suspicion,  lest  it  be  a  cerebral 
hernia,  even  though  it  do  not  pulsate,  or  on  pressure  cause  cere- 
bral symptoms.  In  the  large  cerebral  hernia  death  in  the  first 
few  days  of  life  is,  we  know,  the  rule. 


492  DISEASES    OF    THE    EYE. 

Exophthalmic  Goitre — (Graves'  Disease,  Basedow's  Disease). 

Symptoms. — The  three  cardinal  symptoms  of  this  disease  are  : 
Increased  rapidity  of  the  heart's  action,  which  may  reach 
two  hundred  beats  per  minute ;  tumefaction  of  the  thyroid 
gland,  and  exophthalmos.  Of  these  the  cardiac  symptom  is 
the  most  constant,  and  usually  the  first  to  appear  ;  either,  or 
both,  of  the  others  may  be  wanting.  There  is  often  also  great 
emaciation,  with  outbursts  of  sweating  and  diarrhoea.  A 
venous  murmur  may  be  heard  in  the  neck.  And,  in  females, 
there  is  very  commonly  irregularity,  or  suppression  of 
menstruation. 

The  disease  has  been  observed  at  all  ages,  but  is  most  common 
in  early  adult  life. 

Von  Graefe's  Sign  is  a  very  early,  tolerably  constant,  and 
almost  pathognomonic  one  ;  it  consists  in  an  impairment  of  the 
consensual  movement  of  the  upper  lid  in  association  with  the 
eyeball.  When,  in  the  normal  condition,  the  globe  is  rolled 
downward,  the  upper  eyelid  falls,  and  thus  its  margin  is  kept 
throughout  in  a  constant  relation  to  the  upper  margin  of  the 
cornea.  In  Graves'  Disease  the  descent  of  the  upper  lid  does 
not  take  place,  or  only  in  an  imperfect  manner  ;  and,  conse- 
quently, when  the  patient  looks  down,  a  zone  of  sclerotic  be- 
comes visible  between  the  margin  of  the  lid  and  the  cornea. 
This  symptom  is  often  present  prior  to  any  exophthalmos,  and 
hence  its  great  diagnostic  value.  It  may  also  continue  after  the 
latter  disappears — although  it  is  perhaps  more  common  for 
it  to  disappear  before  the  proptosis — and  it  is  not  seen,  or  but 
very  rarely  so,  in  protrusion  of  the  globe  from  other  causes. 
But  the  sign  is  not  so  absolutely  pathognomonic  as  it  was  held  by 
von  Graefe  to  be.  It  may  be  absent  in  Graves'  Disease,  although 
very  rarely  so  in  the  early  stages,  and  it  is  sometimes  present  in 
other  diseased  states,  and  even  in  health. 

Stellwag's  Sign  is  also  very  constant.  It  is  incompleteness, 
and  diminished  frequency,  of  the  act  of  involuntary  nictitation. 

This  act  occurs  sometimes  only  once  in  a  minute,  or  several 
rapid  nictitations  take  place,  and  then  a  lengthened  pause.    The 


THE   ORBIT.  493 

nictitation  each  time  is  incomplete,  the  margins  of  the  lids  not 
being  brought  together.  The  result  of  this  may  be  that  the 
lower  third  of  the  cornea  becomes  covered  with  pannus  vessels, 
owing  to  the  constant  exposure ;  for  even  during  sleep  the  eye- 
lids remain  partially  open. 

Dalrymple's  Sign  consists  in  an  abnormal  widening  of  the 
palpebral  aperture,  due  to  retraction  of  the  upper  eyelid. 
It  is  this  gaping  of  the  eyelids  which  gives  the  characteristic 
staring  aspect  to  the  patient.  This  sign  is  often  erroneously  at- 
tributed to  Stellwag,  or  is  included  in  his  sign.  The  error  is  due 
to  the  fact  that  in  the  same  paper  *  in  which  Stellwag  first 
drew  attention  to  what  is  above  described  as  his  sign,  he  dis- 
cussed this  other  previously  observed  sign.  According  to  White 
Cooper  t  it  was  Dalrymple  who  first  pointed  out  the  latter.  J 

Probably  each  of  these  "  signs  "  is  due  to  the  one  cause  sug- 
gested by  Sharkey,  §  namely,  loss  of  power  in  the  orbicularis, 
rather  than  over-action  of  the  levator. 

Otto  Becker  states  that,  in  a  majority  of  the  cases,  spontaneous 
pulsation  may  be  seen  in  the  retinal  arteries,  but  I  have  only 
found  it  sometimes.  The  vision — unless  when  corneal  complica- 
tions supervene — and  condition  of  the  pupil  are  unaffected  by 
the  disease.  In  some  cases  there  is  an  increased  flow  of  tears, 
but  most  of  the  patients  complain  of  a  dryness  of  the  eyeballs. 
The  sensibility  of  the  cornea  is  diminished.  Ulcers  of  the  cornea 
are  not  common,  but  are  said  (von  Graefe)  to  be  more  frequent 
in  men  than  in  women,  although  Graves'  Disease  is  more  common 

*  Wiener  Med.  Jahrbucher,  xvii,  p.  25,  1869.  See  also  Klin.  Monatshl. 
fur  Augenheilkunde,  1869,  p.  216,  and  "Graefe  und  Saemisch's  Hand- 
buch,"  vi,  pp.  955  and  956. 

t  The  Lancet,  May  26,  1849,  p.  553. 

t  Other  conditions  which  produce  widening  of  the  palpebral  aperture, 
or  "  Staring  Eye,"  are:  1.  Orbital  Tumor  (mechanically).  2.  Stimu- 
lation of  the  Cervical  Sympathetic.  3.  Cocaine  (in  slight  degree,  prob- 
ably by  reason  of  2. — Jessop).  4.  Women  after  childbirth  (hysteria). 
5.  In  tetanus  (spasm  of  occipito-frontalis).     6.  In  complete  amaurosis. 

^  Trans.  Ophth.  Soc,  vol.  xi,  p.  204. 


494  DISEASES    OF    THE    EYE. 

in  women.  The  exposure  of  the  eye  and  dryness  of  the  cornea 
are  the  chief  causes  of  ulceration,  when  it  occurs ;  but  Sattler 
inclines  to  the  belief  that  it  is  also  largely  due  to  paralysis  of 
the  nervous  supply  of  the  cornea. 

The  patients  are  often  hysterical ;  and  even  marked  psychical 
disturbances  have  been  noted,  such  as  a  peculiar  and  unnatural 
gayety,  rapidity  of  speech,  and  great  irritability ;  or,  on  the  other 
hand,  extreme  depression,  and  even  attempts  at  suicide  have 
been  observed.  Also,  loss  of  memory  and  inability  to  make  a 
mental  effort.  The  motions  of  the  eyeball  have  in  some  cases 
been  defective,  a  fact  for  which  the  exophthalmos  does  not 
account.     Trousseau's  Celebrated  Macula  is  often  well  marked. 

The  Progress  of  the  Disease  is,  as  a  rule,  very  chronic,  extend- 
ing over  months  or  years,  but  liable  to  fluctuations  in  the  inten- 
sity of  its  symptoms.  A  few  cases  have  been  recorded  in  which 
it  became  fully  developed  in  the  course  of  some  hours  or  days. 
After  a  lengthened  period  and  many  fluctuations,  the  symptoms 
usually  slowly  disappear.  Occasionally,  a  slight  permanent 
swelling  of  the  thyroid  may  remain,  and  very  often  more  or  less 
exophthalmos.  About  12  per  cent,  of  the  cases  go  from  bad  to 
worse,  and  end  fatally  from  general  exhaustion,  organic  disease 
of  the  heart,  which  may  have  come  on,  cerebral  apoplexy, 
hemorrhage  from  the  bowels,  or  gangrene  of  the  extremities. 

Causes. — Ansemia  and  chlorosis  are  general  conditions  very 
often  present,  as  are,  also,  irregularities  of  menstruation,  but  it 
is  probable  that  the  latter  should  be  regarded  rather  as  a  con- 
comitant symptom  than  as  a  cause.  Severe  illnesses  are  recorded 
as  having  gone  before  the  onset  in  many  cases,  and  also  excessive 
bodily  or  mental  efforts.  Great  sexual  excitement  has  been 
known  to  be  followed  by  Graves'  Disease,  and  depressing 
psychical  causes  are  not  unfrequent  forerunners  of  it.  In  many 
instances,  however,  the  patients  have  been  perfectly  healthy,  and 
no  cause  could  be  assigned. 

The  Enlargement  of  the  Thyroid  is  due,  in  the  first  instance,  to 
dilatation  of  its  vessels ;  but,  in  a  late  stage,  hypertrophy  of  the 
gland  tissue   may  be  produced,  and  increase  of  its   connective 


THE    ORBIT.  495 

tissue,  and  even  cystic  degeneration.  The  Exophthalmos  is  due 
to  hypersemia  of  the  retro-bulbar  orbital  tissues,  as  is  demon- 
strated by  a  vascular  bruit  often  present,  and  the  fact  that  steady 
pressure  on  the  globe  diminishes  the  protrusion.  Hypertrophy 
of  the  orbital  fat  may  be  found  post-mortem,  but  is,  doubtless, 
secondary  to  the  hyper[:emia. 

The  Theory  until  of  late  widely  held  as  to  the  Nature  of  the 
Disease  represents  it  as  a  lesion  of  the  cervical  sympathetic, 
which  causes  paralysis  of  the  vaso-motor  nerves,  and  consequent 
goitre,  exophthalmos,  and  pulsation  and  dilatation  of  the  caro- 
tids and  retinal  arteries ;  while  it  causes  excited  cardiac  action 
by  reason  of  a  permanent  irritation  of  the  excito-motor  nerves  of 
the  heart,  which  also  run  in  the  cervical  sympathetic.  Here  the 
difficulty  arises,  that  two  of  the  chief  symptoms  are  attempted 
to  be  explained  as  the  result  of  paralysis,  while  the  third  is  said 
to  be  due  to  excitation.  The  absence,  as  a  rule,  of  a  pupillary 
symptom  is  a  strong  argument  against  a  lesion  of  the  sympa- 
thetic. That  a  state  of  continuous  irritation  of  the  sympathetic 
should  exist  is  improbable,  and  is  without  proved  physiological 
analogy.  With  regard  to  paralysis  of  the  sympathetic  causing 
the  goitre  and  exophthalmos,  it  is  doubtful  whether  it  could  do 
so;  for  experimental  division' of  the  sympathetic  has  not  pro- 
duced these  symptoms  in  animals,  nor  have  they  resulted  in 
clinical  cases  of  paralysis  of  that  nerve  in  man,  although 
the  pupillary  symptoms  have  been  marked.  Post-mortem  exami- 
nation has,  no  doubt,  in  a  very  few  instances,  revealed  alter- 
ations in  the  cervical  sympathetic,  but  they  were  of  an 
inconstant  nature,  and  were  wholly  wanting  in  the  vast  majority 
of  cases  which  have  been  microscopically  examined. 

These  considerations  tend  to  discredit  the  sympathetic  theory. 

Professor  Sattler,  of  Leipzig,*  has  advanced  a  theory  which 
is  worthy  of  consideration.  He  assumes  a  lesion  of  those  cir- 
cumscribed portions  of  the  vaso-motor  centre  in  the  brain 
which  preside  over  the  vaso-motor  nerves  of  the  thyroid  gland 

*  "  Graefe  and  Si^misch's  Handbuch,''  vol.  vi,  p.  084,  tt  aeq. 


496  DISEASES   OP   THE    EYE. 

and  of  the  intraorbital  tissue,  and  believes  that  the  great  con- 
stancy with  which  enlargement  of  the  thyroid  and  exophthal- 
mos are  present  indicates  an  intimate  local  relation  of  these  two 
portions.  He  attributes  the  cardiac  symptoms  to  a  lesion  of  the 
cardio-inhibitory  centre  for  the  pneumogastric.  He  also  regards 
Graefe's  symptom  as  due  to  a  central  lesion ;  one,  namely,  ot 
the  co-ordinating  centre  for  the  associated  motions  of  the  lids 
and  eyeball ;  while  Stellwag's  symptom,  he  believes,  as  does 
Stellwag  himself,  to  be  due  to  a  lesion  of  the  reflex  centres, 
which  are  excited  by  stimuli  from  the  retina  and  from  the  sensi- 
tive nerves  of  the  cornea  and  conjunctiva.  Battler's  theory  de- 
rives important  support  from  the  experiments  of  Filehne.* 
When  this  observer  divided  the  restiform  bodies  in  their  upper 
quarter,  although  the  incision  was  not  carried  so  deep  as  to 
wound  the  roots  of  the  vagus,  yet  the  functions  of  the  latter 
nerve  became  impaired,  exophthalmos  was  produced,  and,  al- 
though the  thyroid  did  not  swell,  there  was  vaso-motor  paralysis 
in  the  ears,  thyroid,  and  anterior  part  of  the  neck.  Hence, 
Filehne  concludes  :  that  Graves'  Disease  may  be  produced  by 
paralysis  of  certain  nerve-regions  controlled  by  the  medulla  ob- 
longata, and  that  the  points  traversed  in  common  by  the  nerve- 
paths  concerned  are  the  restiform  bodies;  that  the  exophthalmos 
and  goitre  depend  on  dilatation  of  the  blood-vessels  ;  and  that 
the  increased  heart's  action  is  due  to  diminution  or  abolition  of 
tone  in  the  pneumogastric.  Post  mortem  examinations  in  the 
human  subject  are  necessary  to  establish  Filehne's  theory,  but 
he  points  out  that  negative  results  from  some  of  these  would 
not  be  fatal  to  his  theory,  as  the  occurrence  of  functional  affec- 
tions of  the  central  nervous  system  is  admitted.  Dr.  William 
A.  Fitzgerald  f  has  pointed  out  that  exophthalmic  goitre  is 
frequently  complicated  by  symptoms  which  are  clearly  due  to  a 

^"Zur  Pathogenese  der  Basedow' schen  Krankheit,"  Sitzungsher.  d. 
Phys.  Med.  Sac.  zu  Erlangen,  July  14,  1879,  p.  177.  See  also  "  Graefe 
und  Soemisch's  Handbuch,"  vol.  vi,  p.  1001. 

t"  Theory  of  a  Central  Lesion  in  Exophthalmic  Goitre,"  Dublin 
Journal  Med.  Sc,  March  and  April,  1883. 


THE    ORBIT.  497 

central  lesioD,  such  as  symmetrical  paralysis  of  the  external 
recti,  paralysis  of  the  associated  motions  of  the  eyes,  and  glyco- 
suria. 

Hale  White  has  recorded  *  a  case  of  Graves'  Disease  in 
which,  after  death,  the  only  lesions  were  small  hemorrhages  in 
the  floor  of  the  fourth  ventricle. 

A  very  able  explanation  of  the  marked  preference  shown  by 
the  symptoms  for  the  right  side  of  the  body  is  given  by  Dr.  W. 
A.  Fitzgerald  {loc.  cit).  Bilateral  symmetry  (double  exophthal- 
mos and  swelling  of  each  half  of  the  thyroid),  although  not 
uncommon,  is  not  always  present,  especially  in  the  early  stages  ; 
and  when  want  of  symmetry  exists  the  preponderance  of  the 
symptoms  is  on  the  right  side — the  right  eye  protruded  and  the 
right  lobe  of  the  thyroid  enlarged.  It  has  occurred  to  him  that 
the  extreme  constancy  of  the  cardiac  symptoms  affords  a  clue  to 
the  problem  of  this  preference,  for  he  believes  that  it,  too,  is  a 
right-sided  symptom,  as  it  is  more  than  probable  that  it  is  the 
right  vagus  which  is  chiefly  concerned  in  the  inhibition  of  the 
heart,  and  that  the  left  has  but  little  power  of  the  kind.  Ar- 
loing  and  Tripier's  experiments,!  and  those  of  Masoin  J  and  of 
Meyer,  §  show  this ;  and  several  cases  are  on  record  in  which  ir- 
ritation of  the  right  pneumogastric  in  man  caused  marked  cardiac 
inhibition.  Fitzgerald  thinks,  also,  that  the  mode  of  develop- 
ment of  the  heart  affords  an  explanation  of  the  supply  of  that 
organ  by  the  right  rather  than  by  the  left  vagus;  for,  soon  after 
its  appearance  in  the  embryo,  it  projects  to  the  right  side,  where 
it  comes  in  relationship  with  the  corresponding  vagus. 

Treatment — A  principal  part  of  this  consists  in  the  careful 
regulation  of  the  patient's  general  health  and  functions.  Free- 
dom from  mental  anxiety  and  excitement,  regular  hours, 
moderate  exercise,  and  change  of  air  are  the  most  important 
items. 

*  Brit.  Med.  Journ.,  March  30,  1889. 
t  Archives  de  Physiologie,  tome  v,  p.  166,  1873. 
%  Bull,  de  V Acad.  Roy.  de  Med.  de  Belg.,  tome  vi,  3me  serie,  p.  4. 
§  "Das  Hemmungsnervensystem  des  Herzens,"  p.  61,  1869. 
42 


498  DISEASES   OF   THE   EYE. 

The  fluctuations  which  occur  in  the  intensity  of  the  symptoms 
render  it  difficult  to  arrive  at  definite  conclusions  with  regard  to 
the  efficacy  of  remedies,  a  vast  number  of  which  have  been  tried 
and  lauded  from  time  to  time.  In  mild  forms  of  the  affection, 
and  especially  if  the  anaemia  be  well  marked,  iron  internally  is 
beneficial,  but  in  severe  cases  it  has  the  opposite  effect.  Quinine 
in  moderate  doses  has  been  employed  with  benefit  in  some  cases. 
Trousseau  recommended  digitalis  in  large  doses,  but  its  eflfect 
must  be  watched.  The  beneficial  action  of  iodide  of  potassium 
in  ordinary  goitre  has  suggested  its  use  in  this  disease,  but 
under  its  influence  the  symptoms  are  sometimes  aggravated,  and 
it  is  doubtful  whether  they  are  ever  relieved  by  it.  Mr.  Hulke  * 
speaks  highly  of  aconite,  and  Dr.  Samuel  Wilks  f  has  no  doubt 
as  to  the  value  of  belladonna.  Ergotin  internally  has  been 
tried,  and  with  advantage  in  some  instances.  Sattler  warmly 
recommends  a  well-regulated  hydropathic  treatment,  when  the 
patient  is  not  too  excitable.  Paroxysms  of  cardiac  palpitations, 
etc.,  are  best  combated  with  ice  applied  to  the  head,  heart,  and 
goitre.  The  sympathetic  theory  has  induced  the  trial  of  a  gal- 
vanic treatment  of  the  cervical  sympathetic. 

Dr.  GauthierJ  recommends  antipyrin  before  everything  else. 
Lemke,  of  Hamburg,  §  in  two  cases  removed  one-half  of  the  en- 
larged thyroid,  with  the  result  of  curing  the  exophthalmos  and 
the  excited  heart's  action,  while  the  other  half  of  the  thyroid 
became  spontaneously  reduced  to  normal  size. 

The  great  number  of  remedies  which  have  been  proposed  for 
it  demonstrate  the  incurable  nature  of  most  cases  of  this  disease. 

In  cases  where  the  exophthalmos  is  so  great  that  the  cornea  is 
exposed,  even  during  sleep,  it  is  desirable  to  perform  tarsorraphy 
(p.  148)  ;  and  the  same  operation  is  indicated  when,  the  disease 
having  subsided,  the  exophthalmos  still  remains  to  a  degree 
which  gives  the  patient  a  disagreeable  expression. 

*  Trans.  Ophthal.  Soc,  vol.  vi,  p.  34. 

t  Ibid.,  vol.  vi,  p.  56. 

t  Rev.  cle  M(^d  ,\890,  p.  409. 

3  Deutsche  Med.  Wochenschr.,  Jan.  8,  1891. 


APPENDIX  I 


HOLMGREN'S   METHOD   FOR  TESTING  THE  COLOR-SENSE. 

For  the  purposes  of  this  method,  a  selection  of  Berlin  worsteds  is 
made,  including  red,  orange,  yellow,  yellow-green,  pure  green,  blue- 
green,  blue,  violet,  purple,  pink,  brown,  gray  ;  several  shades  of  each 
color  being  present,  and  at  least  five  gradations  of  each  tint,  from  the 
deepest  to  the  lightest.  Green  and  gray,  several  kinds  each  of  pink, 
blue,  and  violet,  and  the  pale  gray  shades  of  brown,  yellow,  red,  and 
pink,  must  be  well  represented.  But  no  two  samples  are  to  be  of 
precisely  the  same  shade  of  the  same  color.  This  large  number  of 
colors  and  shades  is  used  because  the  color-blind  person  escapes 
detection  with  more  difficulty,  and  the  diagnosis  therefore  is  all  the 
more  certainly  made  the  greater  the  variety  of  colors.  The  normal- 
eyed  individual  readily  selects  the  right  ones  from  the  mass ;  whilst  the 
color-blind  person,  although  the  right  ones  are  directly  before  him,  picks 
out  wrong  ones,  thereby  disclosing  the  character  of  his  defect. 

The  test-color  with  which  Holmgren  invariably  begins  his  examination 
is  a  pale  pure  green,  because  green  is  the  whitest  of  the  spectral  colors, 
and,  consequently,  the  one  in  which  the  presence  of  color  is  most  diffi- 
cult to  recognize — the  one,  in  short,  most  easily  mistaken  for  gray 
(=  no  color).  Furthermore,  as  we  all  experience  the  most  difficulty  in 
deciding  whether  there  be  any  "  color  "  at  all  present  in  the  very  deepest 
shades  (nearly  black),  and  in  the  very  palest  shades  (nearly  white),  it 
was  plainly  either  a  very  dark  or  a  very  pale  shade  of  green  that  should 
be  employed,  and  Holmgren's  experience  made  him  decide  for  the  pale 
shade,  as  providing  the  most  delicate  test. 

As  a  test  for  the  diagnosis  of  the  particular  kind  of  color-blindness, 
Holmgren  recommends  a  purple  (deep  pink)  sample — that  is,  the  whole 
group  of  colors  in  which  red  (orange)  and  blue  (violet)  are  combined  in 
nearly  equal  proportions,  or  at  least  in  such  proportions  that  no  one  of 
them  sufficiently  preponderates  over  the  others,  to  the  normal  sense,  so 
as  to  give  its  name  to  the  combination.  Purple  is  of  especial  importance 
in  the  examination  of  the  color-blind,  for  the  reason  that  it  forms  a 

499 


500  DISEASES   OF    THE    EYE. 

combination  of  two  fundanaental  colors  (red  and  blue) — the  two  extreme 
colors — which  are  never  confounded  with  each  other. 

The  Method  of  Examination  and  of  Diagnosis  is  as  follows:  The 
worsteds  are  placed  in  a  pile  on  a  table  in  broad  daylight.  The  test 
skein  is  taken  from  the  pile  and  laid  at  a  short  distance  from  it,  so  as 
not  to  be  confounded  with  the  other  skeins  during  the  trial,  and  the 
person  examined  is  then  requested  to  select  other  ekeins  most  resem- 
bling this  in  color  and  to  place  them  by  the  side  of  the  sample.  It  is 
necessary  he  should  have  clearly  understood  what  is  required  of  him; 
namely,  that  he  should  search  the  pile  for  the  skeins  making  an  im- 
pression on  his  chromatic  sense  similar  to  that  made  by  the  sample, 
and  independently  of  any  name  he  may  give  the  color.  Indeed,  it  is  not 
desirable  that  he  should  be  asked  to  name  the  colors,  and  he  should  be 
discouraged  from  doing  so,  The  examiner  should  explain  that  resem- 
blance in  every  respect  is  not  necessary  ;  that  no  two  specimens  are  just 
alike ;  that  the  only  question  is  the  resemblance  of  color  ;  and  that, 
consequently,  he  must  endeavor  to  find  something  lighter  and  darker  of 
the  same  color.  If  the  person  examined  cannot  understand  this  verbal 
explanation  the  examiner  must  resort  to  action.  He  must  himself  make 
the  trial  by  searching  with  his  own  hands  for  the  skeins,  thereby  showing 
what  is  meant  by  a  shade,  and  afterward  restoring  the  whole  to  the  pile, 
except  the  sample  skein.  Or,  when  a  large  number  of  persons  have  to 
be  examined  together,  it  will  be  more  rapid  to  begin  at  once  with  such  a 
demonstration  before  the  assemblage.  There  is  no  loss  of  security  in 
this,  for  no  one  with  defective  chromatic  sense  finds  the  correct  skeins 
in  the  pile  any  the  more  easily  from  the  fact  of  having  a  moment  before 
seen  some  one  else  looking  for  and  arranging  them. 

On  the  card  which  is  attached  to  the  inside  of  the  back  cover  of  this 
book  there  are  two  classes  of  wool-samples.  1.  The  Test  Samples,  which 
are  placed  horizontally.  2.  The  Colors  of  Confusion, — that  is,  those 
which  the  color-blind  person  selects  from  the  heap  of  wools,  because  he 
confuses  them  with  the  color  of  the  sample, — and  these  are  arranged 
vertically  under  their  respective  test-samples. 

The  test  is  conducted  as  follows:  Test  I.  The  green  sample  is 
presented.  This  sample,  as  already  explained,  should  be  of  the  palest 
shade  of  very  pure  green,  which  is  neither  yellow-green  nor  blue-green 
to  the  normal  eye,  but  fairly  intermediate  between  the  two.  The 
examination  must  be  continued  until  the  person  examined  has  selected 
all  the  other  skeins  of  the  same  color,  or  else,  with  these  or  separately, 
one  or  several  skeins  of  the  class  corresponding  to  the  "colors  of 
confusion"  (1  to  5),  until  he  has  sufficiently  proved  by  his  manner  of 
doing  it,  that   he  can  easily  and  unerringly  distinguish  the  confusion 


APPENDIX   I.  501 

colors,  or  until  he  has  given  proof  of  unmistakable  difficulty  in 
accomplishing  his  task.  He  who  places  beside  the  sample  one  of  the 
colors  of  confusion  (1  to  5),  that  is  to  say,  finds  that  it  resembles  the 
test  sample,  is  color-blind.  He  who,  without  being  quite  guilty  of  this 
confusion,  evinces  a  manifest  disposition  to  do  so,  has  a  feeble  chromatic 
sense. 

If  we  want  to  know  the  kind  and  degree  of  the  color-blindness 
which  the  failure  to  perform  Test  I  shows  to  be  present,  we  must 
proceed  to — 

Test  Ha.  A  purple  skein  is  shown  to  the  person  being  examined. 
The  trial  must  be  continued  until  he  has  selected  all,  or  the  greater 
part  of,  the  skeins  of  the  same  color,  or  else,  simultaneously  or 
separately,  one  or  several  skeins  of  "confusion"  (6  to  9).  He  who 
confuses,  selects  either  the  light  or  deep  shades  of  blue  and  violet, 
especially  the  deep  shades  (6  and  7),  or  the  light  or  deep  shades  of  one 
kind  of  green  or  gray,  inclining  to  blue  (8  and  9).  1.  He  who  is  color- 
blind by  Test  I,  and  who,  upon  Test  II  a,  selects  only  purple  skeins,  is 
termed  "incompletely  color-blind."  2.  He  who,  in  Test  7/ a,  selects 
with  purple  only  blue  and  violet,  or  one  of  them,  is  "  completely  red- 
blind."  3.  He  who,  in  Test  Ha,  selects  with  purple  only  green  and 
gray,  or  one  of  them,  is  "  completely  green-blind."  The  red  blind  never 
selects  the  colors  taken  by  the  green-blind,  or  vice  versa.  Often  the 
green-blind  places  a  violet  or  blue  skein  beside  the  green,  but  only  the 
brightest  shades  of  these  colors.     This  does  not  influence  the  diagnosis. 

The  examination  may  end  here,  and  the  diagnosis  be  regarded  as 
settled.  But  to  convince  railway  employers,  and  shipowners,  and  their 
employes,  a  still  further  trial  may  be  made.  It  only  serves  to  corroborate 
the  diagnosis. 

Test  lib. — The  red  skein  is  presented.  It  is  necessary  to  have  a 
vivid  red  color,  like  the  red  flag  used  as  signals  on  railways.  This 
test,  which  is  applied  only  to  those  either  "completely  red-blind"  or 
"completely  green-blind,"  should  be  continued  until  the  person  ex- 
amined has  placed  beside  the  specimen  all  the  skeins  belonging  to  this 
shade,  or  the  greater  part  of  them,  or  else,  separately,  one  or  several 
"colors  of  confusion"  (10  to  13).  The  red-blind  then  chooses,  besides 
the  red,  green  and  brown  shades,  which  (10  and  11)  to  the  normal  sense 
seem  darker  than  red.  On  the  other  hand,  the  green  blind  selects 
opposite  shades,  which  appear  lighter  than  red  (12  and  13).  Every  case 
of  complete  color-blindness  discovered  does  not  always  make  the  precise 
mistakes  just  mentioned  with  Test  lib.  These  exceptions  are  either 
persons  with  comparatively  inferior  degrees  of  complete  color-blind- 
ness, or  color-blind  persons  who  have  been  exercised  in  the  colors  of 


502  DISEASES    OF    THE    EYE. 

signals,  and  who  try  not  to  be  discovered.  Tiiey  usually,  but  not  always, 
confound  at  least  green  and  brown.  Total  color-blindness  is  extremely 
rare,  but  such  a  case  would  be  recognized  by  a  confusion  of  every  color 
having  the  same  intensity  of  light. 

Violet-blindness  will  be  recognized  by  a  genuine  confusion  of  purple, 
red,  and  orange  in  Test  II h. 

I  have  described  Holmgren's  Method  at  some  length,  as  it  is  probable 
that  in  the  near  future  (see  footnote  f;  p.  506)  more  importance  will 
be  attached  by  the  Board  of  Trade  to  color-blindness  in  sailors  and  in 
railway  employes  than  has  hitherto  been  the  case.  This  method  has 
been  specially  arranged  for  the  examination  of  persons  in  these  employ- 
ments, and  has  had,  for  many  years,  an  extensive  trial  in  various 
countries.  The  test  is  equally  suited  to  the  examination  of  acquired 
and  of  congenital  color-blindness. 

If  further  information  on  the  subject  be  desired,  the  reader  should 
consult  Professor  Holmgren's  original  monograph,  "  De  la  Cecite  des 
Couleurs,"  Stockholm,  1877,  or  Dr.  Joy  Jeffries'  "Color-Blindness," 
Boston,  1879. 


APPENDIX  II. 

REGULATIONS  AS  TO  DEFECTS  OF  VISION  WHICH  DIS- 
QUALIFY CANDIDATES  FOR  ADMISSION  INTO  THE 
CIVIL,  NAVAL,  AND  MILITARY  GOVERNMENT  SER- 
VICES, THE  ROYAL  IRISH  CONSTABULARY,  AND  THE 
MERCANTILE  MARINE. 

By  an  army  circular  issued  by  the  War  Office  on  September  1,  1887. 
and  which  remains  in  force  : — 

Candidates  for  Commissions  in  the  Army  are  required  to  possess  the 
following  visual  powers.  These  regulations  apply  to  all  branches  of 
service,  including  the  Medical  Department. 

Letters  and  numbers  corresponding  to  Snellen's  Metrical  Test- Types 
(Edition  1885)  will  be  used  for  testing  the  standard  of  vision.  If  a 
candidate's  vision,  measured  by  Snellen's  test-types,  be  such  that  he  can 
read  the  types  numbered  D  =  6  at  6  metres,  or  20  English  feet,  and  the 
types  numbered  D  :=^  0.6  at  any  distance  selected  by  himself,  with  each 
eye  separately,  and  without  glasses,  he  will  be  considered  fit. 

If  a  candidate  cannot  read  with  each  eye  separately,  without  glasses, 


APPENDIX    II.  503 

Snellen's  types  marked  D  =  36  at  a  distance  of  6  metres,  or  20  English 
feet,  i.  e.,  if  he  do  not  possess  one-sixth  of  Snellen's  standard  of  normal 
acuteness  of  vision,  although  he  may  be  able  to  read  the  types  D  =  0.6 
at  some  distance  with  each  eye,  he  will  be  considered  unfit. 

If  a  candidate  can  read  with  each  eye  separately  Snellen's  types  num- 
bered D  =;  36  at  a  distance  of  6  metres,  or  20  English  feet,  without 
glasses,  but  cannot  read  them  beyond  that  distance,  i.e.,  if  he  just  pos- 
sesses one-sixth  of  normal  acuteness  of  vision,  and  his  visual  deficiency 
is  due  to  faulty  refraction,  he  may  be  passed  as  fit,  provided  that,  with  the 
aid  of  correcting  glasses,  he  can  read  Snellen's  type  D  =:  6  at  6  metres, 
or  20  English  feet,  with  one  eye,  and  at  least  Snellen's  types  D  =  12  at 
6  metres,  or  20  English  feet,  with  the  other  eye ;  and,  at  the  same  time, 
can  read  Snellen's  type  marked  D  =  08  with  one  or  both  eyes,  without 
the  aid  of  glasses,  at  any  distance  the  candidate  may  select. 

[i.  e.  As  a  minimum,  a  candidate  must  have  with  each  eye  separately 
V  =  3^  without  glasses  ;  as  well  as  V  =  4  with  one  eye,  and  V  =  ^%  with 
the  other  eye,  with  glasses.] 

Squint,  inability  to  distinguish  the  principal  colors,  or  any  morbid  con- 
dition, subject  to  the  risk  of  aggravation  or  recurrence  in  either  eye,  will 
cause  the  rejection  of  a  candidate. 

The  following  are  taken  from  Sir  Joseph  Fayrer's  "  Regulations  as  to 
Defects  of  Vision,  etc."* 

The  Royal  Navy. — 1.  A  candidate  is  disqualified  unless  both  eyes  are 
emmetropic.  The  candidate's  acuteness  of  vision  and  range  of  accom- 
modation must  be  perfect. 

2.  A  candidate  is  disqualified  by  any  imperfection  of  his  color-sense. 
[The  two  foregoing  rules  do  not  apply  to  the  Medical  Department.] 

3.  Strabismus,  or  any  defective  action  of  the  exterior  muscles  of  the 
eyeball,  disqualifies  a  candidate  for  the  Royal  Navy. 

The  Home  Civil  Service, — With  reference  to  the  Home  Civil  Service, 
the  Commissioners  refer  each  case  to  "a  competent  medical  adviser, 
leaving  him  to  apply  whatever  tests  he  may  deem  suitable,  and  whatever 
standard  the  particular  situation  may  require." 

The  Indian  Civil  Service  {Covenanted  and  Uncovenanted).—!.  A  candi- 
date may  be  admitted  into  the  Civil  Service  of  the  Government  of  India, 
if  ametropic  in  one  or  both  eyes,  provided  that,  with  correcting  lenses, 
the  acuteness  of  vision  be  not  less  than  f  in  one  eye  and  |  in  the  other, 
there  being  no  morbid  changes  in  the  fundus  of  either  eye. 

2.  Cases  of  myopia,  however,  with  a  posterior  staphyloma,  may  be 
admitted  into  the  service,  provided  the  ametropia  in  either  eye  do  not 

*  Second  Edition,  J.  A.  Churchill,  18S7. 


504  DISEASES    OF   THE    EYE. 

exceed  2.5  D.  and  no  active  morbid  changes  of  choroid  or  retina  be 
present. 

3.  A  candidate  who  has  a  defect  of  vision  arising  from  nebula  of  the 
cornea  is  disqualified  if  the  sight  of  either  eye  be  less  than  /v,  and  in 
such  a  case  the  acuteness  of  vision  in  the  better  eye  must  equal  f ,  with 
or  without  glasses. 

4.  Paralysis  of  one  or  more  of  the  exterior  muscles  of  the  eyeball  dis- 
qualifies a  candidate  for  the  Indian  Civil  Service.  In  the  case  of  a  candi- 
date said  to  have  been  cured  of  strabismus  by  operation,  but  without 
restoration  of  binocular  vision,  if  with  correcting  glasses  the  vision  reach 
the  above  standard  (1),  and  if  the  movement  of  each  eye  be  good,  the 
candidate  may  be  passed.  The  same  rule  applies  to  the  case  of  unequal 
ametropia  without  binocular  vision,  both  eyes  having  full  acuteness  of 
vision  with  glasses  and  good  movement. 

The  Indian  Medical  Service. — 1.  A  candidate  may  be  admitted  into 
the  Indian  Medical  Service  if  myopic  to  the  extent  of  5  D.,  provided  that 
with  correcting  lenses  his  acuteness  of  vision  in  one  eye  equal  ^^  and  in 
the  other  f ,  there  being  no  morbid  changes  in  the  fundus  of  the  eyes. 
Cases  of  myopia,  however,  with  a  posterior  staphyloma,  may  be  admitted 
into  the  service,  provided  the  ametropia  in  either  eye  do  not  exceed  2.5 
D.,  the  acuteness  of  vision  with  correcting  glasses  being  equal  to  the 
above  standard,  and  no  active  morbid  changes  of  choroid  or  retina  being 
present. 

2.  Myopic  astigmatism  does  not  disqualify  a  candidate  for  the  service, 
provided  the  combined  spherical  or  cylindrical  glasses  required  to  correct 
the  ametropia  do  not  exceed  —5  D.  ;  the  acuteness  of  vision  in  one  eye 
when  so  corrected  being  equal  to  y^o ,  and  in  the  other  eye  f ;  the  accom- 
modation being  normal  with  the  correcting  glasses,  and  no  progressive 
morbid  changes  of  the  choroid  or  retina  being  present. 

3.  A  candidate  having  total  hypermetropia  not  exceeding  5  D.  is  not 
disqualified  for  the  service,  provided  the  sight  in  one  eye  (when  under 
the  effect  of  atropine)  equal  j^o,  and  in  the  other  f ,  with  +  5  D.  or  any 
lower  power. 

4.  Hypermetropic  astigmatism  does  not  disqualify  a  candidate  for  the 
service,  provided  the  combined  lens  required  to  correct  the  total  hyper- 
metropia do  not  exceed  5  D.  The  acuteness  of  vision  in  one  eye  must 
equal  f^  ^^^  i°  ^^e  other  |,  with  or  without  the  correcting  glass. 

5.  A  candidate  may  be  accepted  with  a  faint  nebula  of  one  cornea, 
reducing  the  vision  to  j%,  provided  the  eye  in  other  respects  be  healthy. 
In  such  a  case  the  better  eye  must  be  emmetropic  and  possess  normal 
vision.     Defects  of  vision  arising  from  pathological  or  other  changes  in 


APPENDIX   11.  505 

the  eye  which  are  not  referred  to  in  the  above  rules  may  exclude  a  can- 
didate for  admission  into  the  Indian  Medical  Service. 

6.  A  candidate  is  disqualified  if  he  cannot  distinguish  the  principal 
colors — red,  green,  violet  or  blue,  yellow,  and  their  various  shades  (Dig- 
chromatopsia). 

7.  Paralysis  of  one  or  more  of  the  exterior  muscles  of  the  eyeball  dis- 
qualifies a  candidate  for  the  Indian  Medical  Service. 

The  Indian  Marine  Service  {Including  Engineers  and  Firemen). — 1. 
A  candidate  is  disqualified  if  he  have  an  error  of  refraction  in  one  or  both 
eyes  which  is  not  neutralized  by  a  concave  or  by  a  convex  1  D.  lens,  or 
some  lower  power. 

2.  A  candidate  is  disqualified  if  he  cannot  distinguish  the  primary 
colors  and  their  various  shades — red,  green,  violet  or  blue,  and  yellow. 

3.  Strabismus,  or  any  defective  action  of  the  exterior  muscles  of  the 
eyeball,  disqualifies  a  candidate  for  the  Marine  Service. 

Royal  Irish  Constabulary. — Candidates  for  cadetships  in  the  Royal 
Irish  Constabulary,  and  recruits,  must  be  able  to  read  with  each  eye 
separately,  and  without  glasses,  Snellen's  metrical  test  types  (Edition 
1882)  numbered  D  =  10,  at  20  English  feet,  and  those  numbered  D  =^  0.8 
at  any  distance  selected  by  the  candidate  himself. 

Squint,  inability  to  distinguish  the  principal  colors,  or  any  morbid 
condition  liable  to  the  risk  of  aggravation  or  recurrence  in  either  eye 
will  involve  the  rejection  of  the  candidate. 

The  British  Mercantile  Marine.* — The  Board  of  Trade  does  not  as 
yet,  although  it  probably  very  soon  will  (see  footnote,  p.  506),  require  a 
boy  on  joining  the  Merchant  Service  to  pass  any  visual  test.  It  is,  how- 
ever, open  to  any  person  about  to  serve  to  submit  himself  to  the  Board 
of  Trade  tests  for  color-blindness. 

On  wishing  to  become  an  officer  (second  mate),  the  sailor's  color- 
vision  is  tested,  f  The  tests  are  as  follows :  Test  I.  Colored  cards.  The 
candidate  is  required  to  select  from  the  whole  number  of  cards  any  one 
or  more  of  a  color  named  by  the  examiner.  The  candidate  is  shown  a 
particular  card,  and  asked  to  name  its  color.  The  candidate  is  required 
to  place  together  all  the  cards  of  one  color.  Test  11.  Colored  glasses. 
The  test  is  made  in  a  dark  room,  and  a  lighted  lamp  or  candle  is  placed 
behind  the  glass.  Attention  is  especially  directed  to  the  candidate's 
ability  to  distinguish  the  red  from  the  green  glass.  Test  III.  In  some 
cases  in  which  the  examiner  decides  that  the  candidate  has  failed,  and  in 

*  For  the  information  contained  in  this  section  I  am  indebted  to  Mr.  Bickerton, 
Liverpool. 

t  Board  of  Trade  Report  upon  the  Tests  for  Color-blindness,  1885. 
43 


506  DISEASES   OF   THE   EYE. 

which  the  latter  holds  a  contrary  opinion,  as  well  as  in  cases  which  may 
raise  a  doubt  in  the  examiner's  mind,  the  facts  are  reported  to  the 
Department,  and  the  applicant  is  re-tested  by  means  of  a  modification 
of  Holmgren's  Test. 

The  candidate  for  his  officer's  certificate  is  not  tested  as  to  his  refraction, 
or  acuteness  of  vision,  except  that  "A  person  who  has  lost  the  sight  of 
one  eye  cannot  be  permitted  to  be  examined  for  a  certificate  of  competency 
either  for  Foreign  or  Home  Trade.  If  he  already  hold  a  certificate,  he 
cannot  be  examined  for  a  certificate  of  a  higher  grade."  * 

In  view  of  the  fact  that  a  sailor,  after  having  spent  some  years  at 
sea,  may  find  himself  disqualified  by  color-blindness  for  his  mate's 
certificate,  it  is  advisable  that  all  boys  should  seek  the  Board  of  Trade's 
Color-Test  Certificate  before  adopting  the  sea  as  their  calling  in  life. 

It  is  evident  that  the  visual  tests  required  by  the  Board  of  Trade  are 
imperfect  and  insufficient,  and  it  is  to  be  hoped  that  measures  will  soon 
be  taken  to  make  them  what  they  ought  to  be.f 

*  Board  of  Trade  Circular,  Xo.  259,  February,  1885. 

f  In  the  autumn  of  1890  a  Committee  of  the  Royal  Society  was  appointed  to 
investigate  the  subject  of  color-blindness  from  a  practical  point  of  view.  In  May, 
1892,  it  issued  its  Report,  in  which  it  recommends  the  systematic  examination  of 
railway  men  and  sailors  of  the  Mercantile  Marine  as  regards  their  color-sense, 
and  also  Holmgren's  Method  as  being  the  simplest  and  most  efficient  test. 


^^Oo 


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vertical  +jq„ 


INDEX 


Abscess  of  the  Cornea,  196,  205 

Accommodation,  amplitude  of,  11  ; 
anomalies  of,  49  ;  cramp  of,  28, 
31,  37,  55  ;  and  convergence,  con- 
nection between,  12;  mechanism 
of,  10  ;  normal,  9  ;  paralysis  of, 
53;  relative,  12;  relative  ampli- 
tude of,  13  ;  voluntary  relaxation 
of  the,  59 

Accommodative  asthenopia,  30,  31, 
55,  82,  261 

Acuteness  of  vision,  the,  18 

Adenoma  of  the  eyelid,  141 

Adaptation  of  the  retina,  16  foot- 
note, 419 

Advancement,  operation  of,  for 
strabismus,  474 

Albinismus,  260 

Albuminuria,  366,  382,  394 

Albuminuric  retinitis,  366,  368, 
389,  394 

Alexia,  415 

Amaurosis,  407;  pretended,  420; 
quinine,  373  ;  spinal,  401  ;  supra- 
orbital, 418,  487 ;  temporary, 
after  blepharospasm,  126 

Amblyopia,  407 ;  alcoholic,  282, 
395  ;  central,  395  ;  due  to  central 
lesions,    407 ;    congenital,    317, 

417,  460,  483 

Amblyopia  ex  anopsia,  458  ;  glyco- 
suric,  404 ;  from  hemorrhage 
(haematemesis,  etc.);  405  ;  hyste- 
rical, 418  ;  from  injury  to  supra- 
orbital nerve,  418,  587  ;   reflex, 

418,  687 ;  in  strabismus,  459 ; 
tobacco,  281,  395;  toxic,  395; 
ursemic,  420 

Ametropia,  25 

Amplitude  of  accommodation,  11  ; 


in  hypermetropia,  28  ;  in  myopia, 
34  ;  in  presbyopia,  49 
Amplitude  of  convergence,  13,  479 
Amyloid  degeneration  of  the  con- 
junctiva, 111 
Anaemia,  367,  386 

progressive  pernicious,  367 
Aneurism  of  central  retinal  artery, 

283 
Angle  alpha,  14 

gamma,  14,  28,  35 

in  hypermetropia,  28 
in  myopia,  35 
the  metre,  13,  479 
of  strabismus,  465 
the  visual,  19 
Aniridia,  242,  245 
Anisometropia,  49 
Ankyloblepharon,  170 
Aphakia,  352 
Aphasia,  413,  414 
Apoplexy,  cerebral,  280 
of  pons  Varolii,  282 
of  retina,  367 
Arcus  senilis,  224 
Argyll- Robertson's    operation    for 
ectropium,  166 
pupil,  281 
Argyrosis,  85 

Arlt-Jaesche   operation  for  trichi- 
asis, 154 
Arlt's  operation  for  ectropium,  169 
Arthritis,  gonorrhoeal,  107,  233 
Asthenopia,  86,  90  ;   accommoda- 
tive, 30,  31,  55    82;    muscular, 
477  ;  neurasthenic,  385  ;  retinal, 
385,  459 
Astigmatism,  25,  39  ;  after  cataract 
operations,    353 ;    estimation   of 
degree  of,  45  ;  irregular,  49,  217, 


507 


508 


DISEASES   OF   THE   EYE. 


342,  344  ;  lental,  48 ;  ophthalmo- 
scopic diagnosis  of,  44,  67,  74  ; 
retinoscopy  in,  74;  spectacles  in, 
45  ;   symptoms  of,  42 
Atheroma,  general,  366,  367,  382, 

384 
Atrophy,  progressive  muscular,  282 
Atropine,  68,  87,  132,  189.  193,  194, 
196,   209,  231,  237,  279,  304, 
306,  315 
poisoning,  238,  279 

Bader's  operation  for  conical  cor- 
nea, 218 
Berlin's  operation   for  entropium, 

162 
Binocular  vision,  468  footnote 
Bisulphide  of   carbon,   amblyopia 

from,  397 
Black  eye,  172 
Blennorrhoea   of   the   conjunctiva, 

99,  194 
of  the  lachrymal  sac,  175 
neonatorum,  99 

prophylaxis  of,  101 
Blepharitis,      intermarginal,      83 ; 

marginal,    83,     135,     174,    180; 

squamosa,    135 ;    ulcerosa,    135, 

152 
Blepharophimosis,  151 
Blepharoptosis,  141 
Blepharospasm,  126,  141 
Blind  spot.  The,  24 
Blow  on  eye,  54,  228,  240,  321,  322, 

352,  356,  377,  387,  403 
Bowman's   operation    for    conical 

cornea,  219 
Brain,    localization   of  disease   in 

the,  147,  412,  415,  416,  417,  446, 

449 
Breast,  cancer  of  the,  258 
Broca's  lobe,  lesion  at,  417 
Bronchitis,  254 
Bulbar  paralysis,  54 
Buphthalmos,  308 

Canaliculus,  obstruction   of  the, 

175 
Canthoplasty,  98,  151 
Capsule,    Lesion   of  the   internal, 

412,  414 
Capsulotomy,  326,  349 


Carcinoma  of  the  choroid,  258 

of  the  orbit,  489 

of  the  breast,  258 
Cardiac  disease,  366,  367,  382,  384 
Caries  of  nasal  bones,  181 
Cataract,  35,  249,  252,  262,  309 

adherent  (or  accreta),  320 

anterior  polar,  or  pyramidal, 
107,  318 

artificial  ripening  of,  315 

black,  313 

calcareous,  320 

capsular,  320 

central  capsular,  107 

central  lental,  228 

complete,  309 

complete,  of  young  people,  317 

congenital,  251,  317 

diabetic,  317 

discission  for,  346 

extraction   of,  without  iridec- 
tomy, 343 

flap  operation  for,  343 

fusiform,  319 

von    Graefe's    operation   for, 
330 

linear  operation  for,  325 

morgagnian,  312 

operations  for,  323 

partial,  317 

posterior  polar,  319 

ripeness  of,  311 

secondary,  319,  349 

senile,  309 

spectacles  after  extraction  of, 
353 

suction  operation  for,  349 

symptoms  of,  313 

three  millimetre  flap  operation 
for,  330 

traumatic,  320 

treatment  of,  322 

zonular,  or  lamellar,  317 
Catarrh,  conjunctival,  83 

spring,  87 
Cautery,  the  actual,  190,  195,  197, 

198,  206,  219,  342 
Cavernous     sinus,    thrombosis    of 

the,  283 
Cerebellum,    tumor    of    the,    390 

footnote,  452 
Cerebral   abscess,    390,   415;    em- 


INDEX. 


509 


bolism,   280;    disease,  142,   153, 
446,  449;  localization,  147,  412, 
449  ;    hemorrhage,  415  ;    soften- 
ing, 415  ;  trauma,  391  ;  tubercle, 
367  ;  tumor,  390,  415,  451 
Chalazion,  138 
Chemosis,  82,  86,  100,  138 
Chloroform  narcosis,  the  pupil  in, 

280 
Chlorosis,  137,  283,  386,  392 
Choked  disc,  389 
Chorea,  382 

Choroid,  central  senile  atrophy  of 
the,  252,  324  ;  coloboma  of  the, 
259  ;  colloid  degeneration  of  the, 
251 ;    congenital  defects  of  the, 
259;    diseases  of  the,  230;    de- 
tachment  of  the.  254 ;    hemor- 
rhage  in  the,   252 ;    injuries   of 
the,   256  ;    tubercle  of  the,   258, 
384 ;  tumors  of  the,  257,  377 
Choroidal  ring,  77 
Choroiditis,  250 
central,  252 

central  senile  guttate,  251 
disseminated,    230,    250,    319, 

371 
purulent,  252 
Choroido-retinitis,  251,  371 
Chromidrosis  palpebrarum,  140 
Ciliary  body,  coloboma  of  the,  244, 
259 
diseases  of  the,  230 
inflammation  of  the,  247, 

306 
injuries  of  the,  249 
new  growths  of  the,  249 
muscle,  action  of  the,  10 

cramp,  of  the,  28,  31,  37, 
55 
Climacteric,  the,  367 
Cocaine,  action  of,  on  the  pupil, 
122,  190,  197,  203,  220,  279,  329 
Coloboma,  congenital,  of  the  cho- 
roid, 259;    of  the  ciliary  body, 
244,  259  ;  of  the  crystalline  lens, 
245  ;  of  the  eyelids,  173  ;  of  the 
iris,  244 
Color-blindness,  16,  396,  402,  419, 

499 
Color-sense,    the,     15,     16,    499 ; 
method  of  testing  the,  16,  499 ; 


in  periphery  of  field,  24  ;    theo- 
ries of  the,  16 
Commotio  retinae,  387 
Congestion  papilla,  369,  389 
Conjugate  lateral  paralysis,  446 
Conjunctiva,  amyloid  degeneration 
of  the,   111  ;    cyst  of  the,  120  ; 
cysticercus  under  the,  120  ;  der- 
moid tumor  of  the,  118  ;  diseases 
of  the,  82  ;    epithelioma  of  the, 
119;  essential  shrinking  of  the, 
114 
Conjunctiva,  hemorrhages  in  the, 
83,  111,  118;   hyaline  degenera- 
tion of  the.  111  ;    hyperaemia  of 
the,   82 ;    injuries    of  the,    121  ; 
lithiasis  of  the,    121  ;    lupus   of 
the,  113  ;  papilloma  of  the,  119  ; 
pemphigus    of    the,     113,    115 ; 
Pinguecula    of    the,    117,    118; 
polypus  of  the,  118  ;  sarcoma  of 
the,   120;    syphilitic   disease    of 
the,    119,    133;     transplantation 
of  the,  150;    tubercular  disease 
of  the.  111;  xerosis  of  the,  114, 
419 
Conjunctival  complication  of  small- 
pox, 110 
Conjunctivitis,  83  ;    catarrhal,   83, 
179,   225;    croupous,    108,  114; 
diphtheritic,  108,  114,  115;    fol- 
licular,   86;      gonorrhoeal,    99; 
granular,  88,  148,  152;  phlycten- 
ular, 123,  124  ;  purulent,  89,  90, 
92,  99,  152,  185,  195 
Corectopia,  243 

Cornea,  abscess  of  the,  185,  196, 
206,  221 ;  absorption  ulcer  of 
the,  198;  arcus  senilis  in  the, 
224  ;  bulla  of  the,  204  ;  calcare- 
ous film  of  the,  210  ;  cauteriza- 
tion of  the,  129,  190  ;  cicatrices 
in  the,  130,  187;  conical,  217; 
deep  ulcer  of  the,  101,194;  der- 
moid tumor  of  the,  118,  219; 
diseases  of  the,  184;  ectasies  of 
the,  211  ;  epithelioma  of  the, 
219;  faceted  ulcer  of  the,  198; 
fibroma  of  the,  219 ;  foreign 
bodies  in  the,  195,  199,  219; 
globosa,  307  ;  herpes  of  the, 
200 ;  infantile  ulceration  of  the. 


510 


DISEASES    OF   THE    EYE. 


with  xerophthalmia,  199;  in- 
flammations of  the.  184:  injuries 
of  the,  195,  206,  219,  306  ;  leu- 
coma  of  the,  188,  221  ;  non- 
ulcerative inflammations  of  the, 
205;  macula  of  the,  188,  221; 
nebula  of  the,  188,221  ;  opacities 
of  the,  76,  187,  221 ;  paracentesis 
of  the,  128,  191,  195,  198,  218 
239  ;  ring  ulcer  of  the,  101,  125 
198;  rodent  ulcer  of  the,  197 
sarcoma  of  the,  219;  sclerotizing 
opacity  of  the,  210,  224,  227 
simple  ulcer  of  the,  194:  staphyl 
oma  of  the,  93,  106,  110,  113 
147,  196,  211,  tattooing  of  the 
222 ;  transplantation  of  the 
223;  tumors  of  the,  219;  ulcera 
tive  inflammations  of  the,  184 
211;  ulcus  serpens  of  the,  196 
206 

Corneal  complications  in  purulent 
conjunctivitis,  100,  104,  194 
in  smallpox,  110 

Cramp  of  accommodation,  28,  31, 
37,  55 
of  the  orbicularis,  126,  141 

Critchett's  operation  in  sympa- 
thetic ophthalmitis,  269 

Croupous  conjunctivitis,  108,  114 

Crus  cerebri,  lesion  of  the,  449,  450 

Cupping,  pathological,  of  the  optic 
disc,  78,  288 
physiological,    of     the     optic 
disc,  78 

Cyclitis,  133,  209,  225,  247 ;  plas- 
tic, 248  ;  purulent,  248  ;  serous, 
209,  248 

Cyst,  meibomian,  138 

of  the  conjunctiva,  120 
of  the  iris,  242 

Cysticercus  in  the  vitreous  humor, 
362;  under  the  conjunctiva,  120; 
under  the  retina,  380 

Cystoid  cicatrix,  299,  342 


Dacryoadenitis,  182 
Dacryocystitis,  acute,  98,  181 

chronic,  179,  196 
Daturine,  279 

Decentration  of  spectacle  gl 
481 


Dermoid    tumors    of    conjunctiva 

and  cornea,  118,  219 
De  Wecker's  operation  for  staphy- 
loma corneae,  213 
Diabetes.   36,    64,    237,   239,   316, 

323,  370,  397,  404,  445 
Dianoux's  operation  for  trichiasis, 

155 
Dilator  pupillae,  276 
Dioptric  unit,  the,  6 

system  of  the  eye,  8 
Dioptry,  the,  6 

Diphtherial  paralysis  of  accommo- 
dation, 64 
Diphtherial    paralysis    of    orbital 

muscles,  445 
Diphtheritic     conjunctivitis,     108, 

114,  115 
Diplopia  in  convergent  concomitant 
strabismus,  457,  467 
crossed,  431 
homonymous,  432 
monocular,  241,  352 
in  insufficiency  of  the  internal 

recti,  478 
in  paralysis  of  orbital  muscles, 
429 
Discission,  316,  317,  346 
Distichiasis,  152 

operations  for,  153 
Duboisine,  279 
Dyslexia,  416 

EccHTMOSis    of   the    conjunctiva, 

83,  111,  118 
Eclipses,  blinding  of  the  retina  in, 

385 
Ectropium,    165  ;   cicatricial,  166  ; 
169,  486  ;  muscular,  165  ;  senile, 
166  ;  spastic,  165 
Egyptian  ophthalmia,  88 
Electrolysis  for  naevi,  140 

for    stricture    of    canaliculus, 

176 
for  trichiasis,  153 
Embolism,  cerebral,  281 

of  retinal  vessels,  381,  397 
Emmetropia.  8 
Endocarditis,  254,  285 
Entropium,     113,     159;      organic, 
160  ;  operations  for,  160;  senile, 
160,  163,  ;  spastic,  160,  163 


INDEX. 


511 


Enucleation  of  the  eyeball,  264, 
268 

Epicanthus,  173 

Epilation  of  eyelashes,  153 

Epilepsy,  43,  281,  478 

Epiphora,  174,  179 

Episcleritis,  225 

Epithelioma  of  the  conjunctiva, 
119;  of  the  cornea,  219;  of  the 
eyelid,  141 

Erysipelas  of  the  eyelids,  132, 181, 
392,  484 

Erythropsia,  354,  422 

Eserine,  86  189,  192,  193,  196,  218, 
219,  279,  331,  333 

Evisceration  of  the  eyeball,  214, 
266 

Exophthalmic  goitre,  147,  492 

Exophthalmos,  pulsating,  489 

Expression  of  granulations,  95  i 

Eyeballs,  the  motions  of  the,  and 
their  derangements,  424 

Eyelids,  adenoma  of  the,  141  ; 
chromidrosis  of  the,  140 ;  colo- 
boma  of  the,  173  ;  cramp  of  the, 
126,  141;  diseases  of  the,  132; 
ecchymosis  of  the,  172;  eczema 
of  the,  132,  135  ;  emphysema  of 
the,  172  ;  epithelioma  of  the, 
141;  erysipelas  of  the,  132,  181, 
392,  487  ;  eversion  of  the,  165  ; 
herpeszoster  of  the,  132;  injuries 
of  the,  172 ;  inversion  of  the, 
159  ;  lupus  of  the,  141  ;  milium 
of  the,  139  ;  molluscum  of  the, 
139;  n?evu8  of  the,  140  ;  restora- 
tion of  an,  170  ;  rodent  ulcer  of 
the,  134;  sarcoma  of  the,  141; 
syphilitic  sores  on  the,  133,  134  ; 
vaccine  vesicles  on  the,  134 

Facet  on  the  cornea,  131 
Facial  centre,  lesion  of  the,  147 
Far  point  and  near  point,  10 
Fluorescin,  186,  197 
Focal  illumination,  76 
Focal  interval,  40 

length  of  a  lens,  3 
Focus,  conjugate,  3 

principal,  of  a  lens,  3 

virtual,  4 
Follicular  conjunctivitis,  83 


Fomentations,  warm.  190 
Form-sense,  the,  15, 18,  414 
Fourth  ventricle,  diseases  of  floor 

of,  443,  445 
Fovea  centralis,  79,  81 
Fracture  of  base  of  the  skull,  118, 

172 
Fundus  oculi,  the  normal,  77,  79 

Gaillard's      sutures     for     entro- 

pium,  163 
Galvano-cautery,  195,  197,198,  206, 

219,  342 
Glaucoma,  111,  204,  207,  210,  239, 
246,  283,  285 ;  acute,  291  ; 
chronic,  287  ;  etiology  of,  295  ; 
•fulminans,  294 ;  hemorrhagic, 
307,  368 ;  pathology  of,  295 
Glaucoma,  primary,  285 

secondary,  227,  236,  240,  242, 
248,  248,  257,  267,  305,  306, 
321,  346,  348 
sub-acute,  294 
treatment  of,  298 
Glaucomatous  degeneration,  294 

ring,  290 
Glioma  of  the  brain,   384  ;  of  the 
optic  nerve,  402  ;  of  the  retina, 
230,  258,  355,  384 
Goitre,  exophthalmic,  147,  492 
Gonorrhoeal    arthritis,     107,    233  ; 

conjunctivitis,  99  ;  iritis,  233 
Gout,  367 
Granular   conjunctivitis,    88,    111, 

114,  197 
Granuloma  of  the  iris,  242 
Green's   operation  for  entropium, 
161 

H.EMATEMESIS,  367,  405 

Haemophthalmos,  228 

Hay  fever,  87 

Headache,  43 

Hemiachromatopsia,  413 

Hemianaesthesia,  414,  416 

Hemianopsia,  407  ;  complete  and 
partial,  408,  412  ;  homonymous, 
273,  408,  412 ;  localization  of 
lesion  in,  412  ;  nasal,  409,  412  ; 
relative  and  absolute,  408  ;  su- 
perior and  inferior,  408,  412 ; 
temporal,  408,  412 


512 


DISEASES   OF   THE    EYE. 


Hemiopic  pupil,  the,  415 

Hemiplegia,  414 

crossed,  147,  450,  452 

Hemorrhage  in  the  anterior  cham- 
ber, 228,  240 

Hemorrhoids,  366 

Bering's   drop   experiment,  468 
footnote 
theory  of  the  color-sense,  16 

Hernia  cerebri,  491 

Herpes  cornese,  200 

zoster  ophthalmicus,  132,  201 

Heterophthalmos,  243 

Hippus,  278 

Holmgren's  tests  for  color-blind- 
ness, 17,  and  Appendix  I 

Hooping  cough,  118,  202 

Hordeolum,  138 

Hotz's  operation  for  entropium, 
164 

Hydrocephalus,  391.  400 

Hydrophthalmos,  307 

Hyoscyamine,  279 

Hypermetropia,  25  ;  amplitude  of 
accommodation  in,  28;  angle  7 
in,  28  ;  asthenopia  in,  30  ;  axial, 
25  ;  curvature,  25  ;  cramp  of 
ciliary  muscle  in,  28  ;  determina- 
tion of  degree  of,  26,  65,  68  ; 
direct  ophthalmoscopic  method 
in,  65  ;  internal  strabismus  in, 
30,  464  ;  latent,  29,  31  ;  mani- 
fest, 29,  31  ;  prescribing  of  spec- 
tacles in,  30  ;  retinoscopy  in, 
68 

Hypermetropic  astigmatism.  41 

Hyphema,  228,  240 

Hypopyon,  125, 186, 194,  195,  201, 
206,  248,  359 

Hysteria,  281,  386,  887,  418 

Illaqueatio,  153 

Image  formed  by  a  lens,  5 

real,  5 

virtual,  5 
Influenza,  epidemic,  54,  445 
Intermittent  fever,  202 
Internal  recti,  insuflficiency  of  the, 
37,  477 

capsule,  lesion  of  the,  414 
Intestinal  worms,  283 
Intraocular  growths,  47 


Intraocular  tension,  104,  234.  235, 
239,  245,  248,  252,  257,  285,  348 

Inverted  ophthalmoscopic  image, 60 

Iridectomy,  245,  298 

in  cataract  operations,  332,  343 
for  glaucoma,  245,  246,  298, 
367 

Irideremia,  242,  245 

Irido-choroiditis,  236,  242,  260 

Iridocyclitis,  209,  210,  230,  236, 
260 

Iridodialysis,  241 

Iridodonesis,  352 

Iridotomy,  247,  351 

Iridoplegia,  283 

Iris,  absence  of  the,  242,  545  ;  an- 
teversion  of  the,  242  ;  coloboma 
of  the,  244  ;  cysts  of  the,  242 ; 
diseases  of  the.  230 ;  foreign 
bodies  in  the,  240  :  granuloma  of 
the,  242 ;  injuries  of  the,  240  ; 
malformations  of  the,  243  ;  new 
growths  in  the,  242;  operations 
on  the,  245;  persistent  pupillary 
membrane  of  the,  243;  posterior 
limiting  membrane  of  the,  276 ; 
prolapse  of  the,  106,  192,  193, 
212  ;  retroflexion  of  the,  241  ; 
rupture  of  the  sphincter  of  the; 
241  ;  sarcoma  of  the,  243 , 
trembling  of  the,  352 ;  tubercle 
of  the,  243 

Iritis,  84,  93,  95,  111.  125,  231, 
342  :  diabetic,  237  ;  gonorrhoeal, 
233  ;  parenchymatous,  231,  234; 
plastic,  231,  233  ;  purulent,  231, 
240  ;  rheumatic,  233.239  ;  serous, 
231,  233,  307  ;  syphilitic,  233, 
234,  240 ;  treatment  of,  237 

Jacob's  ulcer,  134 
Jequirity,  97 

Keratitis,  110,  116,  124,  125,  184; 
bullosa,  204  ;  dendriform,  205  ; 
difi'use  interstitial,  206  ;  fascicu- 
lar, 124,  129;  neuro-paralytic, 
199;  phlyctenular,  123,  125, 199  ; 
punctata,  209,  233,  248,  262  ; 
riband-like,  210;  striped,  340; 
thread-like,  203 

Keratoconus,  217 


INDEX. 


513 


Lachrymal  apparatus,  diseases  of 
the,  174 

canaliculus,  obstruction  of  the, 

175 
duct,  stricture  of  the,  176 
fistula,  182 

gland,  extirpation  of  the,  183 
hypertrophy  of  the,  183 
inflammation  of  the,  182 
obstruction,  82,  175,  177 
punctum,  aversion  of  the,  84, 
132,  166,  174 

inversion  of  the,  174 
malposition  of  the,  174 
occlusion  of  the,  174 
stenosis  of  the,  174 
sac,  acute  inflammation  of  the, 
181. 
blenorrhoea  of  the,  179 
mucocele  of  the,  180 
obliteration  of  the,  182 
Lagophthalmos,  147 
Lamellar  cataract,  317 
Lamina  cribrosa,  77 
Lead  poisoning,  393,  445 
Lens,  action  of  a  concave,  on  rays, 
2 ;    of  a  convex,  on  rays,  2,  3  : 
focal  length  of  a,  3  ;  optical  cen- 
tre of  a,  2  ;    principal  axis  of  a, 
2  ;    principal  focus  of  a,  3  ;    the 
image  formed  by  a,  4 

(crystalline),  absence  of  the, 
352 ;  calcification  of  the, 
236  ;  change  of,  in  accom- 
modation, 10;  coloboma  of 
the,  244 ;  diseases  of  the, 
309  ;  dislocation  of  the,  228, 
306,  351 ;  injuries  to  the, 
306,  320 
Lenses,  cylindrical,  45 

numbering  of  the  trial,  6 
spherical,  2 
Lental  astigmatism,  48 
Lenticonus,  3,  5 
Leucocythemia,  370 
Leucoma,  188,  221 

adherent,  106,  195,  196,  222 
Lice  in  the  eyelashes.  137 
Light  difi'erence  (L   D.),  15 

minimum  (L.  M.),  15 
Light-sense,  the,  15,  291,  372,  373, 
374,  400,  414 


Linear  cataract  extraction,  325 
Lithiasis  of  the  conjunctiva,  121 
Localization,    cerebral,    147,   412, 

449 
Locomotor  ataxy,  281,  283,  445 
Lupus  of  the  conjunctiva,  113 
of  the  eyelid,  141 

Macula  lutea,  diseases  of  the,  36  ; 
nervous  supply  of,  410 ;  normal 
appearances  of  the,  79  ;  ophthal- 
moscopic examination  of  the,  63 

Macula  cornea,  189,  221 

Madarosis,  134 

Maddox's  rod  test,  479 

Mania,  acute,  282,  283 

Massage,  88,  222,  224,  226,  383 

Measles,  84,  206,  254 

Media,  the  intraocular,  7 
the  refracting,  8 

Meibomian  cyst,  138 

Melancholia,  283 

Meningitis,  269,  280,  390,  484 

cerebro-spinal,  253,  254,  280, 

390 
tubercular,  280,  390 

Menstruation,  227,  366,  392,  394 

Mental  derangement,  sign  of,  53, 
346 

Metamorphopsia,  372 

Metre  angle,  13,  479 

Metria,  236,  254,  365,  484 

Metrical  system,  6 

Micropsia,  53,  372 

Military  ophthalmia,  88 

Milium,  139 

Mind-blindness,  417 

Mirror,  concave,  7 
plane,  6 

Molluscum,  139 

Morphium,  action  of,  on  the  pupil, 
280 

Motions  of  the  eyeballs,  424 

Mucocele,  180 

Mules's  operation,  215,  264,  266 

Muscarine,  279 

Muscae  volitantes,  357 

Mydriasis,  53,  282,  437,  484 
traumatic,  242 

Mydriatics,  action  of  the,  279 

Myelitis,  390 

Myopia,  25,  31,  377 ;  amplitude  of 


514 


DISEASES    OF    THE    EYE. 


accommodation  in,  34 ;  angle  > 
in,  35  ;  axial,  31 ;  complications 
of,  36,  377;  cramp  of  accommo- 
dation in,  37  ;  curvature,  32 ; 
detachment  of  retina  in,  36,  377  ; 
determination  of  the  degree  of, 
32,  65,  71  ;  direct  ophthalmo- 
scopic method  in,  65 ;  insuffi- 
ciency of  the  internal  recti  in, 
37,  456,  477  ;  macular  disease 
in,  36  ;  management  of,  37  ;  opa- 
cities in  vitreous  humor  in,  37  ; 
posterior  staphyloma  in,  36  ;  pre- 
scribing of  spectacles  in,  38 ; 
progressive,  36,  37  ;  retinal  hem- 
orrhage in,  36 

Myopic  astigmatism,  41 

Myosarcoma  of  ciliary  body,  250 

Myosis,  280 
spinal,  281 

Myotics,  action  of  the,  79 
use  of,  in  glaucoma,  304 

N^YUS  of  the  eyelids,  140 
Nasal  catarrh,  180,  181,  202 

duct,  stricture  of  the,  176,  179 
Near  point,  10 
Nephritis,  368.  420 
Neurasthenia,  284 
Neurectomy,  optic,  266,  270 
Neurotomy,  optic,  266 
Nicotine,  280 

Night-blindness,  115,  372,  373,  419 
Nuclear  paralysis,  443 
Nyctalopia  (see  Night-blindness) 
Nystagmus,  260,  317,  483 

Occipital  Lobe,  lesion  of  the,  412 

Omphalo-phlebitis,  254 

Opaque  nerve-fibres,  78 

Ophthalmia,  Egyptian,  88  ;  gonor- 
rhoea!, 99;  granular,  88,  148, 
152;  military,  88 ;  phlyctenular, 
123  ;  purulent,  99,  152  ;  tarsi, 
135 

Ophthalmoplegia,  externa,  443 
interna,  53,  443 

Ophthalmoscope,  the,  56 ;  direct 
method  of  examination  by,  68  ; 
estimation  of  refraction  with  the, 
63  ;  indirect  method  of  exami- 
nation by  the,  60 


Optic  nerve,  the,  62,  77 

atrophv  of  the,   132,  230, 
301,392,399,403,403, 
484,  486,  487 
colloid    outgrowths    from 

the,  403 
diseases  of  the,  389 
injuries  of  the,  403 
resection  of  the,  255 
tumors  of  the,  402 
papilla,  62,  77 

cupping  of  the,  78 
287 
radiations,  lesions  of  the,  414 
tract,  lesion  of  an,  415 
neuritis,  230,  261,  389,   400, 
487 

retrobulbar,  393,  395 
with   dropping  of  watf-ry 
fluid  from  nostril,  398 
Optical  axis,  the,  8 

centre,  the,  8 
Orbit,  carcinoma  and  sarcoma  of 
the,    489  ;     caries   of  the,    486  ; 
cysts  of  the,  488  ;  diseases  of  the, 
484;  diseases  of  neighboring  cav- 
ities, 490  ;  exostosis  of  the,  488  ; 
foreign  bodies  in  the,  487  ;   frac- 
ture of  the,    172,    487  ;   inflam- 
mation in  the,    392  ;    injuries  of 
the,  486  ;   penetrating  wounds  of 
the,   487  ;    syphilitic  gumma  of 
the,  485  ;  tumors  of  the,  147,  392, 
487 
Orbital    cellulitis,    484 ;    muscles, 
paralysis  of  the,  429  ;  periostitis, 
485 
Osteo  sarcoma  of  the  choroid,  243 
Ozaena,  179 

Pagenstecher's  ointment,  128 
Pannus,  92,  199 
Panophthalmitis,    110,    200,    228, 

253,  261,  355,  365 
Papillitis,  389 

Papilloma  of  conjunctiva,  119 
Paracentesis   of   the   cornea,   129, 

191,  192,  195,  198,  218,  239 
Parallax,  78,  289 
Parallel  rays,  8 
Paralysis   of  accommodation,    53, 

443 ;  bulbar,  54,  282,  445  ;  of  the 


INDEX. 


515 


cervical  sympathetic,  282 ;  con- 
jugate lateral,  446  ;  diphtherial, 
53,  445  ;  of  the  facial  nerve,  147, 
452 ;  of  the  fifth  nerve,  109  ; 
of  the  fourth  nerve,  433,  451  ; 
general,  of  the  insane,  282,  283, 
401  ;  intermittent  of  the  third 
nerve,  442  ;  of  the  levator  palpe- 
brae  (see  Ptosis);  nuclear,  443; 
of  the  orbital  muscles,  429  ;  of 
the  sixth  nerve,  53,  431,  452  ; 
of  the  sphincter  iridis  (see 
Mydriasis) ;  of  the  third  nerve, 
53,  449,  451 

Pemphigus  of  the  conjunctiva,  113, 
115,  148 

Perimeter,  the  21 

Peritomy,  98 

Phlyctenular    conjunctivitis,     123, 
124 
keratitis,  123,  125,  199,  201 

Phosphene,  377 

Photophobia,  87,  93,  100,  125 

Phtheiriasis  ciliorum,  137 

Phthisis  anterior,  262 
bulbi,  228,  236,  249 

Physostigmine,  279 

Pilocarpine,  189,  279 

Pineal  gland,  tumor  of  the,  451 

Pinguecula,  117 

Pneumonia,  200,  202,  237 

Polycoria,  243 

Polyopia,  monocular,  313 

Polypus  of  the  conjunctiva,  118 

Pons,  lesions  of  the,  147,  282,  445, 
447,  452 

Posterior  staphyloma,  36,  254 

Pregnancy,  368,  382,  420 

Presbyopia,  49 

Prism,  action  of  a,  1 

Proptosis,  485,  487 

Pseudo-glioma,  253,  355,  384 

Psychical  blindness,  417 

Pterygium,  IIG 

Ptosis,  141, 173,  414,  436,  443,  444, 
449 
with    associated    movements, 
146 

Pulsation    in    retinal    vessels,   81, 
290,  294,  493 

Pulvinar,  lesion  in  the,  413,  414 

Punctum    lachrymale,   eversion  of 


the,  84,  132,  166,  174;  inversion 
of  the,  174;  occlusion  of  the,  174 
Punctum  proximum,  10 

remotum,  10,  32  footnote 
Pupil,  action  of  the  mydriatics  on 
the,  279 
action  of  the  myotics  on  the, 

279 
the  Argyll- Robertson,  281 
artificial,  246 
change  of,  in  accommodation, 

10,  275 
contraction  of  the,  272 
in  chloroform  narcosis,  280 
dilatation  of  the,  276 
exclusion  of  the,  231 
hemiopic,  415 
hippus  of  the,  278 
influence  of  the  fifth  nerve  on 
the,  279 
of  the  optic  nerve  on  the, 

272 
of  the  sympathetic  on  the, 

276 
of  the  third  nerve  on  the, 
272 
malposition  of  the,  243 
occlusion  of  the,  232 
reflex  contraction  of  the,  272 
size  of  the,  in  disease,  280 

in  health,  272 
supernumerary,  243 
unrest  of  the,  278 
Pupillary    membrane,    persistent, 

243 
Purulent  conjunctivitis,  89,  90,  99, 
152,  185,  194 
inflammation  of   vitreous  hu- 
mor, 355 
iritis,  231,  240 
retinitis,  365 
Pyaemia,  254,  484 

Quinine  amaurosis,  373 

Recurrent  fever,  237 

Red  vision,  353,  422 

Reflection,  phenomenon  of,  6 

Refraction    and    accommodation, 
normal,  7 
and    accommodation,    abnor- 
mal, 25 


516 


DISEASES   OF   THE    EYE. 


Refraction,  estimation   of  the,  by 
the  upright  image,  63 
estimation   of  the,  by   retino- 

scopy,  68 
the  phenomenon  of,  1 

Resection  of  the  optic  nerve,  266, 
270 

Retina,  adaptation  of  the,  16  foot- 
note, 419  ;  aneurism  of  the  cen- 
tral artery  of  the,  381  ;  apoplexy 
of  the,  367  ;  blinding  of  the,  by 
direct  sunlight,  385  ;  cysticercus 
under  the,  380 ;  detachment  of 
the,  36,  236,  248,  257,  320,  357, 
368,  369,  376;  development  of 
connective  tissue  in  the,  375  ; 
diseases  of  the,  365  ;  embolism 
of  the  central  artery  of  the,  381, 
398  ;  glioma  of  the,  384  ;  hemor- 
rhage in  the,  36,  111,  307,  365, 
367,371,375;  hyperaesthesia  of 
the,  386,  387,  418;  normal,  78; 
septic  aflFections  of  the,  111, 
365  ;  thrombosis  of  the  central 
artery  of  the,  384 ;  traumatic 
oedema  of  the,  387;  anaesthesia 
of  the,  387 

Retinal  affections  in  diabetes,  370 
anaesthesia,  385 
asthenopia,  385,  460 
ischsemia,  373 
vessels,  the,  79 

Retinitis,  230;  albuminuric,  366, 
368,  389,  394;  hemorrhagic, 
365,  370;  leucfemic,  370;  pig- 
mentosa, 373,  419 ;  proliferans, 
375  ;  punctata  albescens,  375  ; 
purulent,  111,  365;  syphilitic, 
371 

Retinoscopy,  68 

Rheumatism,  142.  148,  210,  224, 
226,  227,  232,  233,  236,  239,  393, 
404,  485,  486 

Rodent  ulcer  of  the  cornea,  197 
of  the  eyelid,  134 

S.'Emisch's  ulcer,  195 

Sarcoma  of  the  choroid,  256  ;  of 
the  ciliary  body,  249 ;  of  the 
conjunctiva,  120;  of  the  cornea, 
219  ;  of  the  eyelid,  141  ;  of  the 
iris,  243 ;  of  the  sclerotic,  229 


Scarlatina,  84,  420,  484 

Scleritis,  210,  224,  225,  226 

Sclerosis,  multiple,  394,  398,  401, 
483 

Sclerotic,  diseases  of  the,  225  ;  in- 
juries of  the,  227,  377;  ring,  77; 
tumors  of  the,  229 

Sclerotizing  opacity  of  the  cornea, 
210,  224,  227 

Sclerotomy,  303 

Scorbutus,  420 

Scotoma,  central,  252,  396,  402, 404, 
419  ;  positive,  357,  372,  385  ; 
relative,  375,  396 

Septicaemia,  236,  365 

Shadow-test,  the,  68 

Short-sight,  31 

Sight,  the  sense  of,  15 

Skull,  fracture  of  the,  118,  172, 
400,  403 

Smallpox,   conjunctival    and    cor- 
neal complications  of,  111, 
206 
ocular  sequelae  of,  84,  111,  206, 
236 

Snellen's  operation  for  entropium, 
160;  sutures,  166 

Snow-blindness,  420 

Soul-blindness,  417 

Spectacles  in  accommodative  as- 
thenopia, 30,  31  ;  in  albinismus, 
260 ;  in  anisometropia,  49  ;  in 
aphakia,  353 ;  in  astigmatism, 
45  ;  in  conical  cornea,  217  ;  in 
convergent  strabismus,  466,  476; 
in  cramp  of  accommodation,  29; 
in  hypermetropia,  30,  82 ;  in  in- 
cipient cataract,  315;  in  insuffi- 
ciency of  the  internal  recti,  480  ; 
in  irideremia,  245 ;  in  myopia, 
38  ;  in  nebulous  cornea,  222  ;  in 
paralysis  of  accommodation,  55  ; 
in  paralysis  of  orbital  muscles, 
441  ;  in  presbyopia,  51,  82 

Sphenoidal  fissure,  periostitis  at 
the,  53 

Spinal  amaurosis,  401 

cord,  diseases  of  the,  281,  282, 

283,  284,  394,  398,  400 
myosis,  281 

Spring  catarrh,  87 

Squint  (see  Strabismus) 


INDEX. 


517 


Staphyloma,  anterior,  227,  294 
of  the   cornea,   93,   106,   110, 

196,  211 
posterior,  36,  254 

Stenopaeic  spectacles,  218,  222,  260, 
818 

Stomach,  hemorrhao;e  from  the,  404 

Strabismus,  apparent  convergent. 
35  ;  apparent  divergent,  28 

Strabismus,  convergent  concomi- 
tant, 30,  453 ;  advancement  of 
capsule  of  tenon  in,  452;  advance- 
ment of  external  rectus  in,  474  ; 
amblyopia  in,  458 ;  angle  of, 
465  ;  clinical  varieties  of,  460  : 
dangers  of  operation  for,  476  : 
hypermetropia  in,  30,  454,  466  ; 
476  ;  measurement  of,  460;  mo- 
bility of  eye  in,  466  ;  operation 
for,  469,  471 ;  orthoptic  treatment 
of,  466  ;  single  vision  in,  457  ; 
tenotomy  in,  471 

Strabismus,  divergent  concomitant, 
477;  tenotomy  in,  481;  treat- 
ment of.  481 

Streatfield's  operation  for  entro- 
pium,  160 

Strumous  ophthalmia,  123 

Stye,  138 

Symblepharon,  122,  148^  ^ 

Sympathetic  ophthalmitis,  209, 
210,  215,  242,  249.  253,  260,  359 

Sympathetic  irritation,  261,  418 

Synchysis,  356,  357 
scintillans,  357 

Synechia,  anterior,  106,  242,  306 
posterior,  231,  235,  236,  306 

Syphilis,  53,  89,  119,  133,  142,  148. 
176.  208,  210,  224.  226,  227,  230, 
233,  234,  236,  240,  243,  251,  252, 
254,  355,  357,  366,  371,  375,  392, 
398,  440,  485,  486 

Syphilis  of  the   conjunctiva,   119, 
133 
inherited,  208,  236,  251,  254, 
371 

Syphilitic  choroido-retinitis,  371  ; 
iritis,  233,  234,  240;  retinitis, 
371 

Tabes  dorsalis,  2S1,  283,  445 
Tarsal  tumor,  138 


Tarsorraphy,  148,  165 
Tattooing  the  cornea,  222 
Teeth,  diseases  of  the,  484 
Tension  of  the  eyeball,  285,  286 
Test-types,  19 
Third   pair,   paralysis   of  the,   53, 

450,  451 
Trachoma,  88 

Transplantation     of     conjunctiva, 
150;  of  cornea,  223:  of  skin,  170 
Trial  lenses,  numbering  of  the,  0 
Trichiasis,  152 

operations  for,  153 
Tubercle  of  the  brain,  367 

of  the  choroid,  258,  384 

of  the  conjunctiva.  111,  134 

of  the  iris,  243 
Tubercular  meningitis,  280,  390 
Typhoid  fever,  237,  484 

Upright   ophthalmoscopic  image, 

58 
Uremia,  369,  370,  420 
Urfemic  amblyopia,  420 
Uterine  derangements,  386 

hemorrhage,  404 
Uveal  tract,  diseases  of  the,  230 


Vaccine  vesicles  on  the  eyelids, 
134 

Van  Milligen's  operation  for  tri- 
chiasis, 158 

Virtual  focus,  4 
image,  5 

Vision,  acuteness  of,  18:  binocular, 
468,  468  footnote,  477,  477  foot- 
note :  central,  20  :  eccentric,  20  ; 
field  of,  20 ;  defects  of.  which 
disqualify  for  the  army,  5C2  ;  for 
the  Army  Medical  Department, 
502  ;  for  the  British  Mercantile 
Service,  505  ;  for  the  Home  Civil 
Service,  503 ;  for  the  Indian 
Civil  Service,  503  ;  for  the  Indian 
Marine  Service,  505 ;  for  the 
Indian  Medical  Service,  504 ; 
for  the  Navy,  503  ;  for  the  Royal 
Irish  Constabulary,  505 

Visual  angle,  the,  19 
centre,  409 

lesion  at  the,  412 
'  memory,  417 


518 


DISEASES   OF   THE   EYE. 


Vitreous  humor,  cysticercus  in  the, 
362;  detachment  of  the,  362; 
diseases  of  the,  855.  377  ;  fluidity 
of  the,  356,  357;  foreign  bodies 
in  the,  358  ;  hemorrhage  in  the, 
356,  369 ;  inflammatory  pro- 
cesses in  the,  355,  359 ;  muscae 
volitantes  of  the,  357  ;  opacities 
in  the,  37,  111,  230,  236,  248, 
355,  356,  371  ;  persistent  hya- 
loid artery  in  the,  362;  puru- 
lent inflammation  of  the,  257 ; 
355,  359 

Von  Graefe's  operation  for  cata- 
ract, 329;  for  conical  cornea, 
218  ;  for  entropium,  164  ;  in  sym- 
pathetic ophthalmitis,  267 


Vossius's  operation  for  trichiasis, 
157 

Wharton    Jones's    operation  for 

ectropium,  169 
Whooping  cough,  118,  254 
Word-blindness,  415 

Xanthelasma  of  the  eyelids,  140 
Xerophthalmia,     114,    419 ;     with 
ulceration  of  cornea,  199 

Young-Helmholtz   theory  of  the 
color-sense,  16 

Zonula  of  Zinn,  change  of,  in  ac- 
commodation, 10 
Zonular  cataract,  317 


CATALOGUE    No.  7. 


JANUARY,    1894. 


BOOKS 

FOR 

STUDENTS, 

INCLUDING   THE 

PQUIZ-COMPENDS? 


CONTENTS. 

PAGE 

PAGE! 

New  Series  of  Manuals,  2,^,4,'^ 

Obstetrics 10 

Anatomy, 

.            .6 

Pathology,  Histology, .         .11 

Biology, 

.    II 

Pharmacy is 

Chemistry,     . 

.    6 

Physical  Diagnosis,      .         .  11 

Children's  Diseases, 

.     7 

Physiology,   .         .         .         .11 

Dentistry, 

,     8 

Practice  of  Medicine,    .     ii,  12 

Dictionaries, 

8,16 

Prescription  Books,       .         .  12 

Eye  Diseases, 

.     8 

?Quiz-Compends?     .     14,15 

Electricity,   . 

•     9 

Skin  Diseases,       .         .         .12 

Gynaecology, 

.  10 

Surgery  and  Bandaging,       .  13 

Hygiene, 

•     9 

Therapeutics,         .         .         .9 

Materia  Medica,  . 

•    9 

Urine  and  Urinary  Organs,     13 

Medical  Jurisprudence 

.  10 

Venereal  Diseases,        .         .  13 

Nervous  Diseases, 

.  10 

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No.  3.    ANATOMY.     Sixth  Edition. 

311  ILLUSTRATIONS. 
Holden's  Anatomy.  A  Manual  of  the  Dissections  of 
the  Human  Body.  By  John  Langton,  f.  r.  c.  s..  Sur- 
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No.  4.    PHYSIOLOGY.     Sixth  Edition. 

254  ILLUSTRATIONS  AND  A  GLOSSARY. 
A  Manual  of  Physiology.  By  Gerald  F.  Yeo,  m.d., 
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A  Manual.  By  J.  F.  Goodhart,  m.d.,  Phys.  to  the 
Evelina  Hospital  for  Children ;  Asst.  Phys.  to 
Guy's  Hospital,  London.  Second  American  Edition. 
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of  Pennsylvania,  and  Physician  to  the  Children's  Hos- 
pital, Phila.  Containing  many  new  Prescriptions,  a  list 
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copoeia, and  Directions  for  making  Artificial  Human 
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book  on  general  medicine  and  labeling  it  '  Diseases  of  Children,' 
but  has  steadily  kept  in  view  the  diseases  which  seemed  to  be 
incidental  to  childhood,  or  such  points  in  disease  as  appear  to  be  so 
peculiar  to  or  pronounced  in  children  as  to  justify  insistence  upon 
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No.  6.    MATERIA  MEDICA,  PHARMACY, 
PHARMACOLOGY,  AND  THE- 
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TOXICOLOGY. 

THIRD  REVISED  EDITION. 
By  John  J.  Reese,  m.d.,  Professor  of  Medical  Jurispru- 
dence and  Toxicology  in  the  University  of  Pennsyl- 
vania ;  President  of  the  Medical  Jurisprudence  Society 
of  Phila. ;    Third  Edition,  Revised  and  Enlarged. 
"This  admirable  text-book." — Amer.Jour.  of  Med.  Sciences. 
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the  essential  points." — Cincinnati  Lancet  and  Clinic. 

No.  8.    DISEASES  OF  THE  EYE.    176  Illus. 

FOURTH  EDITION. 
Diseases  of  the  Eye  and  their  Treatment.  A  Handbook 
for  Physicians  and  Students.  By  Henry  R.  Swanzy, 
A.M.,  M.B.,  F.R. C.S.I. ,  Surgeon  to  the  National  Eye  and 
Ear  Infirmary ;  Ophthalmic  Surgeon  to  the  Adelaide 
Hospital,  Dublin;  Examiner  in  Ophthalmic  Surgery 
in  the  Royal  University  of  Ireland.  Fourth  Edition, 
Thoroughly  Revised.  176  Illustrations  and  a  Zephyr 
Test  Plate.     500  pages. 

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6  STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

ANATOMY. 

Morris'  New  Text-Book  on  Anatomy.  Now  Ready.  By- 
ten  leading  Surgeons  and  Anatomists,  and  Edited  by  Henry 
Morris,  f.r.c.s.  791  Specially  Engraved  Illustrations,  214  ot 
which  are  printed  in  colors.     Octavo.     1280  pages. 

Price  in  Cloth,  7.50  ;  Sheep,  8.50  ;  Half  Russia,  9.50 
***  Send  for  Descriptive  Circular  and  Sample  Pages. 

Macalister's  Human  Anatomy.  816  Illustrations.  A  new 
Text-book  for  Students  and  Practitioners,  Systematic  and  Topo- 
graphical, including  the  Embryology,  Histology,  and  Morphology 
of  Man.  With  special  reference  to  the  requirements  of 
Practical  Surgery  and  Medicine.  With  816  Illustrations, 
400  of  which  are  original.     Octavo.       Cloth,  7.50;   Leather,  8.50 

Ballou's  Veterinary  Anatomy  and  Physiology.  Illustrated. 
By  Wm.  R.  Ballou,  m.d.,  Professor  of  Equine  Anatomy  at  New 
York  College  of  Veterinarj'  Surgeons.  29  graphic  Illustrations. 
lamo.  Cloth,  1. 00;  Interleaved  for  notes,  1.25 

Holden's  Dissector.  A  manual  of  Dissection  of  the  Human 
Body.  Sixth  Edition.  Edited"  by  A.  Hewson,  m.d..  Demonstra- 
tor of  Anatomy  at  Jefferson  Medical  College.  311  Illustrations, 
many  of  which  are  new.  Oil-cloth,  3.00;  Sheep,  3.50 

Holden's  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Dehneations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone  and 
its  Development.  With  Lithographic  Plates  and  Numerous  Illus- 
trations.    Seventh  Edition,     Svo.  Cloth,  6.00 

Holden's  Landmarks,  Medical  and  Surgical.   4th  Ed.  Clo.,i.2S 

Potter's  Compend  of  Anatomy.  Fifth  Edition.  Enlarged. 
16  Lithographic  Plates.     117  Illustrations.     See  page  14. 

Cloth,  1. 00;  Interleaved  for  Notes,  1.25 

CHEMISTRY. 

Bartley's  Medical  Chemistry.  Second  Edition.  A  text-book 
prepared  specially  for  Medical,  Pharmaceutical,  and  Dental  Stu- 
dents. With  50  Illustrations,  Plate  of  Absorption  Spectra,  and 
Glossary  of  Chemical  Terms.    Revised  and  Enlarged.    Cloth,  2.50 

Trimble.  Practical  and  Analytical  Chemistry.  A  Course  in 
Chemical  Analysis,  by  Henry  Trimble,  Prof,  of  Analytical  Chem- 
istry in  the  Phila.  College  of  Pharmacy.  Illustrated.  Fourth 
Edition,  Enlarged.     Svo.  Cloth,  1.50 

Bloxam's  Chemistry,  Inorganic  and  Organic,  with  Experiments. 
Seventh  Edition.  281  Illustrations.  Cloth,  4.50  ;  Leather,  5.5a 
tS"  See  pages  2  to  3  for  list  0/ Students'  Manuals . 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.         7 

Chemistry  : —  Continued. 

Richter's  Inorganic  Chemistry.  Fourth  American,  from  Sixth 
German  Edition.  Translated  by  Prof.  Edgar  F.  Smith,  ph.d. 
89  Wood  Engravings  and  Colored  Plate  of  Spectra.     Cloth,  2.00 

Richter's  Organic  Chemistry,  or  Chemistry  of  the  Carbon 
Compounds.     Illustrated.     Second  Edition.  Cloth,  4.50 

Symonds.  Manual  of  Chemistry,  for  the  special  use  of  Medi- 
cal Students.  By  Bkandreth  Symonds,  a.m.,  m.d.,  Asst. 
Physician  Roosevelt  Hospital,  Out-Patient  Department ;  Attend- 
ing Physician  Northwestern  Dispensary,  New  York.     Cloth,  2.00 

Leffmann's  Compend  of  Chemistry.    Inorganic  and  Organic 
Including  Urinary  Analysis.     Third  Edition.     Revised. 
See  page  13.  Cloth,  i. 00;    Interleaved  for  Notes,  1.25 

Muter.  Practical  and  Analytical  Chemistry.  Fourth  Edi- 
tion. Revised,  to  meet  the  requirements  of  American  IMedical 
Colleges,  by  Prof.  C.  C.  Hamilton.     Illustrated.  Cloth,   1.25 

Holland.  The  Urine,  Common  Poisons,  and  Milk  Analysis, 
Chemical  and  Microscopical.  For  Laboratory  Use.  Fourth 
Edition,  Enlarged.     Illustrated.  Cloth,  i.oo 

"Woody.  Essentials  of  Chemistry  for  the  Medical  Student. 
Third  Edition.  Cloth,  1.25 

CHILDREN. 

Goodhart  and  Starr.  The  Diseases  of  Children.  Second 
Edition.  By  J.  F.  Goodhart,  m.d.,  Physician  to  the  Evelina 
Hospital  for  Children;  Assistant  Physician  to  Guy's  Hospital, 
London.  Revised  and  Edited  by  Louis  Starr,  m.d..  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Containing  many  Prescriptions  and  Formulae, 
conforming  to  the  U.  S.  Pharmacopoeia,  Directions  for  making 
Artificial  Human  Milk,  for  the  Artificial  Digestion  of  Milk,  etc. 
Illustrated.  Cloth,  3.00;  Leather,  3.50 

Hatfield.  Diseases  of  Children.  By  M.  P.  Hatfield,  m.d.. 
Professor  of  Diseases  of  Children,  Chicago  Medical  College. 
Colored  Plate.     i2mo.  Cloth,  i.oo;  Interleaved,  1.25 

Starr.  Diseases  of  the  Digestive  Organs  in  Infancy  and 
Childhood.  With  chapters  on  the  Investigation  of  Disease, 
and  on  the  General  Management  of  Children.  By  Louis  Starr, 
M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Univer- 
sity of  Pennsylvania.  Illus.  Second  Edition.  Cloth,  2.25 
9^  See  pages  14  and  is  for  list  0/ f  Quiz- Comp ends? 


8  STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

DENTISTRY. 

Fillebrown.     Operative  Dentistry.     330  lUus.  Cloth,  2.50 

Flagg's  Plastics  and  Plastic  Filling.     4th  Ed.         Cloth,  4.00 
Gorgas.     Dental  Medicine.     Fourth  Edition.  Cloth,  3.30 

Harris.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery 
and  Mechanism.  Twelfth  Edition.  Revised  and  enlarged  by 
Professor  Gorgas.  1028  Illustrations.  Cloth,  7.00  ;  Leather,  8.00 
Richardson's  Mechanical  Dentistry.  Sixth  Edition.  By 
Warren.     6co  Illustrations.     8vo.  Cloth,  4.50;  Leather,  5.50 

Sewill.     Dental  Surgery.     200  Illustrations.     3d  Ed.    Clo.,  3.00 
Taft's  Operative  Dentistry.    Dental  Students  and  Practitioners. 
Fourth  Edition.     100  Illustrations.        Cloth,  4.25  ;  Leather,  5.00 
Talbot.      Irregularities   of  the   Teeth,  and   their  Treatment. 
Illustrated.     8vo.     Second  Edition.  Cloth,  3.00 

Tomes'  Dental  Anatomy.     Third  Ed.      191  Illus.      Cloth,  4.00 
Tomes'  Dental   Surgery.      3d  Edition.     292  Illus.    Cloth,  5.00 
Warren.    Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    Illustrated.     2d  Ed.  Cloth,  i. 00;  Interleaved,  1.25 

DICTIONARIES. 

Gould's  New  Medical  Dictionary.  Containing  the  Definition 
and  Pronunciation  of  all  words  in  Medicine,  with  many  useful 
Tables  etc.    ^  Dark  Leather,  3.25  ;  %  Mor.,  Thumb  Index,  4.25 

Gould's  Pocket  Dictionary.  12,000  Medical  Words  Pro- 
nounced and  Defined.  Containing  many  Tables  and  an 
Elaborate  Dose  List.     Thin  64mo. 

Leather,  gilt  edges,  i.oo;  with  Thumb  Index,  1.25 

Harris'  Dictionary  of  Dentistry.  Fifth  Edition.  Completely 
revised  by  Prof.  Gorgas.  Cloth,  5.00;   Leather,  6.00 

Cleaveland's  Pronouncing  Pocket  Medical  Lexicon.  Small 
pocket  size.  Cloth,  red  edges  .75     pocket-book  style,  i.oo 

Longley's  Pocket  Dictionary.  The  Student's  Medical  Lexicon, 
giving  Definition  and  Pronunciation,  with  an  Appendix  giving 
Abbreviations  used  in  Prescriptions,  Metric  Scale  of  Doses,  etc. 
24rao.  Cloth,  I.oo;  pocket-book  style,  1.25 

EYE. 

Hartridge  on  Refraction.     5th  Edition.     Illus.  Cloth,  2.00 

Swanzy.     Diseases  of  the  Eye  and  their  Treatment.     176 

Illustrations.     Fourth  Edition.  Cloth,  3  00;   Leather,  3  50 

Fox  and   Gould.    Compend  of  Diseases   of     the    Eye   and 

Refraction.     2d  Ed.     Enlarged.     71  Illus.     39  Formulae. 

Cloth.  I.oo;  Interleaved  for  Notes,  1.25 
ij®"  See  pages  2to  S  for  list  of  Students'  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.  9 

ELECTRICITY. 

Bigelow.    Plain  Talks  on  Medical  Electricity.  Cloth,  i.oo 

Mason's  Compend  of  Medical  Electricity.  Cloth,  i.oo 

Steavenson  and  Jones.     Medical  Electricity.  A  Practical 

Handbook.     Just  Ready.     Illustrated.     i2mo.  Cloth,  2.50 

HYGIENE. 

Coplin  and  Bevan,  Practical  Hygiene.  By  W.  M.  L.  Cop- 
lin,  Adjunct  Professor  of  Hygiene,  Jefferson  Medical  College, 
Philadelphia,  and  Dr.  D.  Bevan.     Illustrated.  Cloth,  4.00 

Parkes'  (Ed.  A.)  Practical  Hygiene.  Seventh  Edition,  en- 
larged.     Illustrated.     8vo.  Cloth,  4.50 

Parkes'  (L.  C.)  Manual  of  Hygiene  and  Public  Health. 
Second  Edition.     12010.  Cloth,  2.50 

■Wilson's  Handbook  of  Hygiene  and  Sanitary  Science. 
Seventh  Edition.     Revised  and  Illustrated.  Cloth,  3.25 

MATERIA  MEDICA  AND  THERAPEUTICS. 

Potter's  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  'Writing.  Fifth  Edition,  revised  and  improved. 
See  page  i^.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Uavis.  Essentials  of  Materia  Medica  and  Prescription 
"Writing.  By  J.  Aubrey  Davis,  m.d.,  Demonstrator  of  Obstet- 
rics and  Quiz-Master  on  Materia  Medica,  University  of  Penn- 
sylvania.    i2mo.     Interleaved.  Net,  1.50 

Biddle's  Materia  Medica.  Twelfth  Edition.  By  the  late 
John  B.  Biddle,  m.d.  Revised  by  Clement  Biddle,  m.d.  8vo. 
Illustrated.  Cloth,  4.25;  Leather,  5.00 

Potter.  Handbook  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.  Including  Action  of  Medicines,  Special  Thera- 
peutics, Pharmacology,  etc.  By  Saml.  O.  L.  Potter,  m.d., 
M.R.c.p.  (Lond.),  Professor  of  the  Practice  of  Medicine  in 
Cooper  Medical  College,  San  Francisco.  Fourth  Revised  and 
Enlarged  Edition.     776  pages.     8vo.    Cloth,  4.00;  Leather,  5.00 

White  and  W^ilcox.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  A  Handbook  for  Students. 
By  Wm.  Hale  White,  m.d.,  f.r.c.p.,  etc.,  Physician  to  and 
Lecturer  on  Materia  Medica,  Guy's  Hospital.  Revised  by 
Reynold  W.  Wilcox,  m.d..  Professor  of  Clinical  Medicine  at  the 
New  York  Post  Graduate  Medical  School,  Assistant  Physician 
Bellevue  Hospital,  etc.  American  Edition.  Clo.,  3.00;  Lea., 3.50 
J¥S^  See  pages  14  and  /j  for  list  of  f  Quiz- Comp ends  f 


10        STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

MEDICAL  JURISPRUDENCE. 

Reese.  A  Text-book  of  Medical  Jurisprudence  and  Toxi- 
cology. By  John  J.  Reese,  m.d.,  Professor  of  Medical  Juris- 
prudence and  Toxicology  in  the  Medical  Department  of  the 
University  of  Pennsylvania ;  Physician  to  St.  Joseph's  Hospital.. 
Third  Edition.  Cloth,  3.00;  Leather,  3.50- 

NERVOUS  DISEASES. 

Gowers.  Manual  of  Diseases  of  the  Nervous  System, 
A  Complete  Textbook.  By  William  R.  Gowers,  m.d..  Prof. 
Clinical  Medicine,  University  College,  London.  Physician  ta 
National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged,  and  in  many  parts  Rewritten. 
With  many  new  Illustrations.     Octavo. 

Vol.  I.      Diseases  of  the  Nerves  and  Spinal  Cord.      616 

pages.  Cloth,  3.5a 

Vol.   II.     Diseases   of   the    Brain   and   Cranial    Nerves. 

General  and  Functional  Diseases.  Cloth,  4.50 

Ormerod.  Diseases  of  Nervous  System,  Student's  Guide  to. 
By  J.  A.  Ormerod,  m  d.,  Uxon.,  f.k.c.p.  (London),  Member  Path- 
ological. Clinical,  Ophthalmological,  and  Neurological  Societies, 
Physician  to  National  Hospital  for  Paralyzed  and  Epileptic  and 
to  City  of  London  Hospital  for  Diseases  of  the  Chest,  Demon- 
strator of  Morbid  Anatomy,  St.  Bartholomew's  Hospital,  etc^ 
With  75  Wood  Engravings.  Cloth,  2.oo> 

OBSTETRICS  AND  GYNECOLOGY. 

Davis.  A  Manual  of  Obstetrics.  By  Edw.  P.  Davis,  Clinical 
Lecturer  on  Obstetrics,  Jefferson  Medical  College,  Philadelphia. 
Colored  Plates,  and  136  other  Illustrations.     i2mo.      Cloth,  2.00 


Byford.     Diseases  of  Women.     The  Practice  of  Medicine  and 
Surgery,  as  applied  to  the  Diseases  and  Accidents  Incident 
Women.    By  W.  H.  Byford,  a.m.,  m.d..  Professor  of  Gyna;colo, 


Surgery,  as  applied  to  the  Diseases  and  Accidents  Incident  to 
Women.  By  W.  H.  Byford,  a.m.,  m.d..  Professor  of  Gynaecology 
in  Rush  Medical  College  and  of  Obstetrics  in  the  Woman's  Med- 


ical College,  etc.,  and  Henrj'  T.  Byford,  m.d..  Surgeon  to  the 
Woman's  Hospital  of  Chicago.  Fourth  Edition.  Revised  and 
Enlarged.  306  Illustrations,  over  100  of  which  are  original. 
Octavo.     832  pages.  Cloth,  5.00  ;  Leather,  6.00. 

Lewers'  Diseases  of  'Women.  A  Practical  Text-book.  13^ 
Illustrations.     Second  Edition.  Cloth,  2.50- 

Parvin's  Winckel's  Diseases  of  Women.  Second  Edition. 
Including  a  Section  on  Diseases  of  the  Bladder  and  Urethra. 
150  III  us.     Revised.     Seepages.  Cloth,  3.00;  Leather,  3.50- 

Wells.      Compend  of  Gynaecology.     Illustrated.      Cloth,  i.oo 

Winckel's  Obstetrics.  A  Text-book  on  Midwifery,  includ- 
ing the  Diseases  of  Childbed.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology,  and  Director  of  the  Royal  University  Clinic  for 
Women,  in  i\lunich.  Authorized  Translation,  by  J  Clifton 
Edgar,  m.d.,  Lecturer  on  Obstetrics,  University  Medical  Col- 
lege, New  York,  with  nearly  200  handsome  Illustrations,  the 
majority  of  which  are  original.  8vo.  Cloth,  6.00  ;  Leather,  7.00 
4S=-  See  page*  2  to  5  for  list  0/ Netv  Manuals. 


STUDENTS'   TEXT-BOOKS   AND   MANUALS.         11 


Obstetrics  and  Gyncecology  : — Continued. 

Landis'  Compend    of   Obstetrics.      Illustrated.     5th  Edition, 

Enlarged.     By  Wells.      Cloth,  i. 00  ;    Interleaved  for  Notes,  1.25 

Galabin's  Midwifery.  By  A.  Lewis  Galabin,  m.d.,  f.r.c.p. 
227  Illustrations.  Leather,  3.50 

PATHOLOGY,  HISTOLOGY,  ETC. 

Stirling.  Outlines  of  Practical  Histology.  A  ^Manual  for 
Students.     2d  Edition.     368  Illustrations.     i2mo.  Cloth,  3.00 

Wethered.  Medical  Microscopy.  By  Frank  J.  Wethered. 
M.D.,  M  R.C.P.     98  Illustrations.  Cloth,  2.50 

Hall.  Compend  of  General  Pathology  and  Morbid  Anat- 
omy.    Illustrated.  Cloth,  i.oo;   Interleaved,  1.25 

Gilliam's  Essentials  of  Pathology.  A  Handbook  for  Students. 
47  Illustrations.     i2mo.  Cloth,  2.00 

Virchow's  Post-Mortem  Examinations.     3d  Ed.    Cloth,  i.co 

PHYSICAL  DIAGNOSIS. 

Fenwick.  Student's  Guide  to  Physical  Diagnosis.  7th 
Edition.     117  Illustrations.     i2mo.  Cloth,  2.25 

Tyson's  Student's  Handbook  of  Physical  Diagnosis.  Illus- 
trated.    2d  Edition.     i2mo.  Cloth,  1.50 

PHYSIOLOGY. 

Yeo's  Physiology.  Sixth  Edition.  The  most  Popular  Stu- 
dents' Book.  By  Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of 
Physiology  in  iting's  College,  London.  Small  Octavo.  254 
carefully  printed  Illustrations.  With  a  Full  Glossary'  and  Index. 
See  page  3.  Cloth,  3.00;  Leather,  3.50 

Brubaker's  Compend  of  Physiology.  Illustrated.  Seventh 
Edition.  Cloth,  i.oo;    Interleaved  for  Notes,  1.25 

Kirke's  Physiology.  New  13th  Ed.  Thoroughly  Revised  and 
Enlarged.  502  Illustrations,  some  of  which  are  printed  in  colors. 
{Blakiston's  Authorized  Edition.)    Red  CI. ,  4.00  ;  Leather,  5.00 

Landois'  Human  Physiology.  Including  Histology  and  Micro- 
scopical Anatomy,  and  with  special  reference  to  Practical  Medi- 
cine. Fourth  Edition.  Translated  and  Edited  by  Prof  Stirling. 
845  Illustrations.  Cloth,  7.00 ;  Leather,  8.00 

"  With  this  Text-book  at  his  command,  no  student  could  fail  in 

his  examination." — Lnncet. 

Sanderson's  Physiological  Laboratory.  Being  Practical  Ex- 
ercises for  the  Student.     350  Illustrations.     8vo.  Cloth,  5.00 

PRACTICE. 

Taylor.  Practice  of  Medicine.  A  Manual.  By  Frederick 
Tavlor,  m.d..  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London  ;  Physician  to  Evelina  Hospital  for  Sick  Chil- 
dren, and  Examiner  in  Materia  Medica  and  Pharmaceutical 
Chemistry,  University  of  London.         Cloth,  2.00;  Leather,  2.50 

M^S'  See  pages  14  and  15  for  list  of  ? Quiz-Compends  f 


12        STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

Practice  : — Continued. 

Roberts'  Practice.  New  Revised  Edition.  A  Handbook 
of  the  Theory  and  Practice  of  Medicine.  By  Frederick  T. 
Roberts,  m.d.,  m.r.c.p.,  Professor  of  Clinical  Medicine  and 
Therapeutics  in  University  College  Hospital,  London.  Seventh 
Edition.     Octavo.  Cloth,  5.50  ;  Sheep,  6.50 

Hughes.  Compend  of  the  Practice  of  Medicine.  4th  Edi- 
tion. Two  parts,  each,  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 
Part  i. — Continued,  Eruptive  and   Periodical  Fevers,  Diseases 

of  the  Stomach,  Intestines,   Peritoneum,  Biliary  Passages,  Liver, 

Kidneys,  etc.,  and  General  Diseases,  etc. 

Part   ii. — Diseases   of   the   Respiratory    System,    Circulatory 

System,  and  Nervous  System ;  Diseases  of  the  Blood,  etc. 

Physicians'  Edition.    Fourth  Edition.    Including  a  Section 
on  Skin  Diseases.   With  Index,    i  vol.   Full  Morocco,  Gilt,  2.50 

From  John  A.  Robinson,  M.D.,  Assistant  to  Chair  of  Clinical 
Medicine ,  now  Lecturer  on  Materia  Medica,  Rush  Medical  Col- 
lege, Chicago. 
"  Meets  with   my  hearty  approbation   as   a   substitute  for  the 

ordinary  note  books  almost  universally  used  by  medical  students. 

It  is  concise,  accurate,  well  arranged,  and  lucid,     .     .     .    just  the 

thing  for  students  to  use  while  studying  physical  diagnosis  and  the 

more  practical  departments  of  medicine." 

PRESCRIPTION   BOOKS. 

Wythe's  Dose  and  Symptom  Book.  Containing  the  Doses 
and  Uses  of  all  the  principal  Articles  of  the  Materia  Medica,  etc. 
Seventeenth  Edition.  Completely  Revised  and  Rewritten,  yusi 
Ready.     32mo.  Cloth,  i. 00;    Pocket-book  style,  1.25 

Pereira's  Physician's  Prescription  Book.  Containing  Lists 
of  Terms,  Phrases,  Contractions,  and  Abbreviations  used  in 
Prescriptions,  Explanatory  Notes,  Grammatical  Construction  of 
Prescriptions,  etc.,  etc.  By  Professor  Jonathan  Pereira,  m.d. 
Sixteenth  Edition.     32mo.     Cloth,  i. 00;   Pocket-book  style,  1.25 

PHARMACY. 

Stewart's  Compend  of  Pharmacy.  Based  upon  Remington's 
Text-book  of  Pharmacy.  Fourth  Edition,  Revised  in  accordance 
with  US    P.,  i8go.  Cloth,  i.oo  ;   Interleaved  for  Notes,  1.25 

Robinson.  Latin  Grammar  of  Pharmacy  and  Medicine. 
By  H.  D.  Robinson,  ph.d.,  Professor  of  Latin  Language  and 
Literature,  University  of  Kansas,  Lawrence.  With  an  Intro- 
duction by  L.  E.  Sayre,  ph.g..  Professor  of  Pharmacy  in,  and 
Dean  of,  the  Dept.  of  Pharmacy,  University  of  Kansas.  i2mo. 
Second  Edition.  Cloth, 2.00 

SKIN  DISEASES. 

Crocker.  Diseases  of  the  Skin,  their  Description,  Pathology, 
Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
hniptions  of  Children.  By  H.  Radcliffe  Crocker,  F.R.f  p..  Phy- 
sician for  Diseases  of  the  Skin  in  I  niversity  College  Hospital. 
Second  Edition.     Revised  and  Enlarged,  with  92  Wood-cuts. 

Cloth,  500 

Van  Harlingen  on  Skin  Diseases.  A  Handbook  of  the  Dis- 
eases of  the  Skin.  By  Arthur  Van  Harlingen,  m.d.  3d  Edition. 
Enlarged  and  Illustrated.     i2mo.  In  Press. 

4£^  See  pages  2  to  5  for  list  0/ New  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.        13 

SURGERY   AND    BANDAGING. 

Moullin's  Surgery,  by  Hamilton.  600  Illustrations  (some 
colored),  200  of  which  are  original.     Second  Edition. 

Cloth,  net,  7.00 ;  Leather,  net,  8.00 ;  Half  Russia,  net,  9.00 
***  Complete  circulars,  with  sample  pages  and  Illustrations,  free 

upon  application. 

Jacobson.  Operations  in  Surgery.  A  Systematic  Handbook 
for  Physicians,  Students,  and  Hospital  Surgeons.  By  W.  H.  A. 
Jacobson,  b  a.  Oxon.,  fji.c.s.  Eng. ;  Ass't  Surgeon  Guy's  Hos- 
pital ;  Surgeon  at  Royal  Hospital  for  Children  and  Women,  etc. 
199  Illustrations.  1006  pages.  8vo.  Cloth.  5.00;  Leather,  6.00 
Heath's  Minor  Surgery,  and  Bandaging.  Tenth  Edition.  142 
Illustrations.     60  Formulae  and  Diet  Lists.  In  Press. 

Horwitz's     Compend     of    Surgery,    Minor     Surgery    and 
Bandaging,    Amputations,    Fractures,    Dislocations,   Surgical 
Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential 
Diagnosis  and  Treatment.     By  Orville  Hokwitz,  b.s.,  m.d.. 
Demonstrator  of  Surgery,  Jefferson  Medical  College.   5th  Edition. 
Enlarged  and  Rearranged.    Many  new  Illustrations  and  Formulae, 
lamo.         Cloth,  i.oo  ;  Interleaved  for  the  addition  of  Notes,  1.25 
***The  new  Section  on  Bandaging  and  Surgical  Dressings  con- 
sists   of   32    Pages  and    41    Illustrations.      Every   Bandage  of   any 
importance   is   figured.      This,  with    the  Section   on   Ligation  ol 
Arteries,  forms  an  ample  Text-book  for  the  Surgical  Laboratory. 
"Walsham.    Manual  of  Practical  Surgery.     Third  Edition. 
By  Wm.  J.  Walsham.  m.d.,  f.r  c.s.,  Asst.  Surg,  to,  and  Dem- 
of  Practical  Surg,  in,  St.  Bartholomew's  Hospital;  Surgeon  to 
Metropolitan   Free  Hospital,  London.      With   318    Engravings. 
See  page  2.  Cloth,  3.00 ;  Leather,  3.50 

URINE,  URINARY   ORGANS,  ETC. 

Holland.  The  Urine,  and  Common  Poisons  and  The 
Milk.  Chemical  and  Microscopical,  for  Laboratory  Use.  Illus- 
trated.    Fourth  Edition.     i2mo.     Interleaved.  Cloth,  i.oo 

Ralfe.  Kidney  Diseases  and  Urinary  Derangements.  42  Illus- 
trations.    i2mo.     572  pages.  Cloth,  2. 75 

Marshall  and  Smith.  On  the  Urine.  The  Chemical  Analysis  ot 
the  Urine.     Colored  Plates.     i2mo.  Cloth,  i.oo 

Memminger.     Diagnosis  by  the  Urine.     Illus.       Cloth,  i.oo 
Tyson.     On  the  Urine.     A  Practical  Guide  to  the  Examination 
of  Urine.     With  Colored  Plates  and  Wood  Engravings.     Eighth 
*  'Edition,  Enlarged.    i2mo.  Cloth,  1.50 

Van  Niiys,  Urine  Analysis.    Illus.  Cloth,  2.00 

VENEREAL  DISEASES. 

Hill  and  Cooper.  Student's  Manual  of  Venereal  Diseases, 
writh  Formulae.     Fourth  Edition.     i2mo.  Cloth,  i.oo 

4^  See  pages  14  and  z^  for  list  0/  ?  Quiz- Cotnp ends  f 


POUIZ-COMPENDS? 

The  Best  Compends  for  Students'  Use 
in  the  Quiz  Class,  and  when  Pre- 
paring for  Examinations. 

Compiled  in  accordance  with  the  latest  teachings  of  promt' 
nent  Lecturers  and  the  ?nost popular  Text-books. 

They  form  a  most  complete,  practical,  and  exhaustive 
set  of  manuals,  containing  information  nowhere  else  col- 
lected in  such  a  condensed,  practical  shape.  Thoroughly 
up  to  the  times  in  every  respect,  containing  many  new 
prescriptions  and  formultTe,  and  over  two  hundred  and 
fifty  illustrations,  many  of  which  have  been  drawn  and 
engraved  specially  for  this  series.  The  authors  have  had 
large  experience  as  quiz-masters  and  attaches  of  colleges, 
with  exceptional  opportunities  for  noting  the  most  recent 
advances  and  rnethods. 

Cloth,  each  $i.oo.     Interleaved  for  Notes,  $1.25. 
No.  I.    HUMAN  ANATOMY,  "Based  upon  Gray."     Fifth 
Enlarged  Edition,  including  Visceral  Anatomy,  formerly 
published     separately.       16     Lithograph     Plates,     New 
Tables,  and   117   other   Illustrations.      By  Samuel   O.  L. 
Potter,  m.a.,  m.d.,  m.r.c.p.  (Lond.),  late  A.  A.  Surgeon  U.  S. 
Army,  Professor  of  Practice,  Cooper  Medical  College,  San  Fran- 
cisco. 
Nos.  2  and  3.     PRACTICE  OF  MEDICINE.     Fourth  Edi- 
tion.    By  Daniel  E.  Hughes,  m.d.,  Demonstrator  of  Clinical 
Medicine  in  Jefferson  Medical  College,  Philadelphia.  In  two  parts. 
Part  I. — Continued,  Eruptive,  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 
Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (includmg  Phy- 
sical Diagnosis),  Circulatory  System,  and  Nervous  System;  Dis- 
eases of  the  Blood,  etc. 

*:).*  These  little  hooks  can  be  regarded  as  a  full  set  of  notes  upon 
the  Practice  of  Medicine,  containing  the  Synonyms,  Definitions, 
Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each 
disease,  and  including  a  number  of  prescriptions  hitherto  unpub- 
lished. 

No.  4.  PHYSIOLOGY,  including  Embryology.  Seventh 
Edition.  By  Albert  P.  Brubakek,  m.d..  Prof,  of  Physiology, 
Penn'a  College  of  Dental  Surgery  ;  Demonstrator  of  Physiology 
in  Jefferson  Medical  College,  Philadelphia.  Revised,  Enlarged, 
with  new  Illustrations. 
No.  5,  OBSTETRICS.  Illustrated.  Fifth  Edition.  By 
Henry  G.  Landis,  m.d.  Edited  by  William  H.  Wells,  m.d.. 
Assistant  Demonstrator  of  Clinical  Obstetrics,  Jefferson  College, 
Philadelphia.     New  Illustrations. 


BLAKISTON'S  ?  QUIZ-COMPENDS  ? 

No.  6.  MATERIA  MEDICA,  THERAPEUTICS,  AND 
PRESCRIPTION    WRITING.     Fifth   Revised   Edition. 

With  especial  Reference  to  the  Physiological  Action  of  Drugs, 
and  a  complete  article  on  Prescription  Writing.  Based  on  the 
Last  Revision  of  the  U  S.  Pharmacopoeia,  and  including  many 
unofficinal  remedies.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
M.R.c.p  (Lond.),late  A.  A.  Surg.  U.  S.  Army;  Prof,  of  Practice, 
Cooper  Medical  College,  San  Francisco.  Improved  and  Enlarged, 
with  Index. 

No.  7.  GYN.®COLOGY.  A  Compend  of  Diseases  of  Women. 
By  Wm.  H  Wells,  m.d.,  Ass't  Demonstrator  of  Obstetrics, 
Jefferson  Medical   College,   Philadelphia.      Illustrated. 

No.  8.  DISEASES  OF  THE  EYE  AND  REFRACTION, 
including  Treatment  and  Surgerj'.  By  L.  Webster  Fox,  m.d.. 
Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Med- 
ical College,  etc.,  and  Geo.  M.  Gould,  m.d.  71  Illustrations,  39 
Formulse.     Second  Enlarged  and  improved  Edition.    Index. 

No.  9.  SURGERY,  Minor  Surgery  and  Bandaging.  Illus- 
trated. Fifth  Edition.  Including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations,  and  other  operations;  Inflam- 
mation, Suppuration,  Ulcers,  Syphilis,  Tumors,  Shock,  etc. 
Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d.. 
Demonstrator  of  Surgery',  Jefferson  Medical  College.  Revised 
and  Enlarged.     98  Formulae  and  167  Illustrations. 

No.  10.  CHEMISTRY.  Inorganic  and  Organic.  For  Medical 
and  Dental  Students.  Including  Urinary  Analysis  and  Medical 
Chemistry.  By  Henry  Leffmanm,  m.d.,  Prof,  of  Chemistry  in 
Penn'a  College  of  Dental  Surgery,  Phila.  Third  Edition,  Revised 
and  Rewritten,  with  Index. 

No.  II.  PHARMACY.  Based  upon  "  Remington's  Text-book 
of  Pharmacy."  By  F.  E.  Stewart,  m.d.,  ph.g. ,  Quiz-Master 
at  Philadelphia  College  of  Pharmacy.    Fourth  Edition,  Revised. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOL- 
OGY. 29  Illustrations.  By  Wm.  R.  Ballou,  m.d.,  Prof,  of 
Equine  Anatomy  at  N    Y.  College  of  Veterinary  Surgeons. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDI- 
CINE. Containing  all  the  most  noteworthy  points  of  interest 
to  the  Dental  student.  Second  Edition.  By  Geo.  W.  Warren, 
D.D.S.,  Clinical  Chief,  Penn'a  College  of  Dental  Surgery',  Phila- 
delphia.    Second  Edition,  Enlarged  and  Illustrated. 

No.  14.  DISEASES  OF  CHILDREN.  By  Dr.  Marcus  P. 
Hatfield,  Prof,  of  Diseases  of  Children,  Chicago  Medical 
College.     Colored  Plate. 

No.  15.  GENERAL  PATHOLOGY  AND  MORBID 
ANATOMY.  By  H.  Newbery  Hall,  m.  d.,  Lecturer  on 
Pathology  and  Surgery  Post  Graduate  School;  Surgeon  Emer- 
gency Hospital,  Chicago,  etc.     Illustrated. 

Botmd  is  Cloth,  $1.    Isterleaved,  for  the  Addition  of  Kotos,  $1.25. . 

J|^*  No  series  of  books  are  so  complete  in  detail,  concise 
in  language^  or  so  well  printed  and  boufid.  Each  one 
forms  a  complete  set  of  notes  upon  the  subject  laider  con- 
sideration. 

Illustrated  Descriptive  Circular  Free. 


23,000  COPIES 
Of  These  Books  Have  Already  Been  Sold, 

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Medical  Dictionary, 

Based  on  Secent  Medical  Literature. 


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Plain  Dark  Leather,  without  Thumb  Index, 3-25 


A  compact,  concise  Vocabulary,  including  all 
the  Words  and  Phrases  used  in  medicine,  with- 
their  proper  Pronunciation  and  Definitions. 


"One  pleasing  feature  of  the  book  is  that  the  reader  can  almost 
invariably  find  the  definition  under  the  word  he  looks  for,  without 
being  referred  from  one  place  to  another,  as  is  too  commonly  the 
case  in  medical  dictionaries.  The  tables  of  the  bacilli,  micrococci, 
leucomai'nes  and  ptomaines  are  excellent,  and  contain  a  large 
amount  of  information  in  a  limited  space.  The  anatomical  tables 
are  also  concise  and  clear.  .  .  .  We  should  unhesitatingly 
recommend  this  dictionary  to  our  readers,  feeling  sure  that  it  wilt 
prove  of  much  value  to  them." — Americati  Journal  of  Medical 
Science. 

JUST  PUBLISHED. 
GOULD'S    POCKET    DICTIONARY.     12,000 
;    Medical  Words  Pronounced  and  Defined. 
^.  Leather,  gilt  edges,  ^i.oo;  with  Thumb  Index,  ^1.25 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  belo\t. 


I 


JUN    7fi£C^ 

fttOMED  JUN  01*8$ 

^fOMED  LIB. 

JUN  1  6  1986 

REC'D 


Form  L9-40m-5,'67(H2161s8)4939 


CARD    EXPLANATORY    OF    J 
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Red  Blindness. 


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Test  II.  a. 


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N.B. — This  Card  is  merelij  intended  to  illustrate  the  text  {(Jhaj).  I. 
and  Appendix  I.),  and  not  itself  /or  icse  as  a  test. 


